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Subdural Empyema Treatment & Management

  • Author: Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM; Chief Editor: Niranjan N Singh, MD, DM  more...
 
Updated: Dec 08, 2015
 

Medical Care

Prehospital care

Maintain an adequate airway and ensure breathing and circulation by supportive care (eg, oxygen). Establish an intravenous line with adequate monitoring while en route to the emergency department.

Emergency department care

Continue supportive treatment (ie, ABCs) directed toward stabilizing the patient. Request necessary imaging studies and laboratory tests. Commence antibiotic therapy as soon as possible with broad coverage for anaerobes, staphylococci, and aerobic streptococci.

The neurosurgical team should be involved; thoracic surgery and otolaryngology teams also should be consulted if necessary.

Other

Antibiotic therapy[4] alone may be adequate for small subdural empyema (ie, < 1.5 cm diameter). Because of the aggressive nature of this disease, however, this option is not widely utilized. This is an option for patients with major contraindications to surgery or significant mortality risks.

Other medical interventions may include medications for seizure treatment or prophylaxis. Treatment for increased intracranial pressure also has been advocated.

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Surgical Care

Immediate neurosurgical drainage[5] of the subdural empyema should be considered. The primary surgical option is craniotomy, which allows wide exposure, adequate exploration, and better evacuation of the purulent collection than other procedures. Stereotatic burr hole placement with drainage and irrigation is another option but is less desirable because of decreased exposure and possible incomplete evacuation of the purulent material.[6]

Drainage and debridement of the primary source of infection may be necessary. Samples should be collected for Gram staining, culture, and sensitivity tests.

Patients with contraindications to surgery or significant mortality risks may receive antibiotic therapy alone.[7]

Other surgical interventions may be required to debride or evacuate the primary source of infection. Such efforts may require an otolaryngologist for paranasal sinusitis (eg, bilateral antral washout, mastoidectomy for recurrent chronic mastoiditis, grommets for recurrent otitis media) or a thoracic surgeon for a chronic lung abscess.

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Consultations

See the list below:

  • Neurosurgery, otolaryngology, and thoracic surgery consultations
  • Physical medicine and rehabilitation for physical therapy, gait and balance training, occupational therapy, and speech therapy
  • Clinical psychologist for treatment of any residual cognitive deficit
  • Ophthalmology or optometry consult if a visual defect is present, especially in patients with palsies of cranial nerves III, V, or VI, or visual field defects (eg, homonymous hemianopsia)
  • Home care aides and social work for issues after discharge (About 55% of patients have neurological deficits on discharge.)
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Activity

Maintaining balance and gait training is important; patients should be assessed and treated in conjunction with the rehabilitation department.

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Contributor Information and Disclosures
Author

Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM Attending Interventional Physiatrist, Wellspan Health

Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM is a member of the following medical societies: American College of Sports Medicine, American Academy of Physical Medicine and Rehabilitation, Royal College of Surgeons of England, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Medical Informatics Association, Association of Academic Physiatrists, International Society of Physical and Rehabilitation Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Lorenzo, MD, MHA, CPE Founding Editor-in-Chief, eMedicine Neurology; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, MHA, CPE is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American Academy of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Florian P Thomas, MD, PhD, Drmed, MA, MS Director, National MS Society Multiple Sclerosis Center; Professor and Director, Clinical Research Unit, Department of Neurology, Adjunct Professor of Physical Therapy, Associate Professor, Institute for Molecular Virology, St Louis University School of Medicine; Editor-in-Chief, Journal of Spinal Cord Medicine

Florian P Thomas, MD, PhD, Drmed, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Niranjan N Singh, MD, DM Associate Professor of Neurology, University of Missouri-Columbia School of Medicine

Niranjan N Singh, MD, DM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

Additional Contributors

Edward L Hogan, MD Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina

Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, Society for Neuroscience, American Society for Biochemistry and Molecular Biology, American Academy of Neurology, American Neurological Association, Phi Beta Kappa, Sigma Xi, Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

References
  1. Zimmerman RD, Leeds NE, Danziger A. Subdural empyema: CT findings. Radiology. 1984 Feb. 150(2):417-22. [Medline].

  2. Chen CY, Huang CC, Chang YC. Subdural empyema in 10 infants: US characteristics and clinical correlates. Radiology. 1998 Jun. 207(3):609-17. [Medline].

  3. Brennan MR. Subdural empyema. Am Fam Physician. 1995 Jan. 51(1):157-62. [Medline].

  4. Greenlee JE. Subdural empyema. In: Mandell GL, ed. Principles and Practice of Infectious Diseases. Vol 1. 4th ed. New York: Churchill. 1994:900-903.

  5. Feuerman T, Wackym PA, Gade GF. Craniotomy improves outcome in subdural empyema. Surg Neurol. 1989 Aug. 32(2):105-10. [Medline].

  6. French H, Schaefer N, Keijzers G, Barison D, Olson S. Intracranial subdural empyema: a 10-year case series. Ochsner J. 2014 Summer. 14 (2):188-94. [Medline].

  7. Sanford JP. Guide to antimicrobial therapy. Bethseda MD: Uniformed Services University Health Sciences. 1993. 3:

  8. Delgado Tapia JA, Galera Lopez J, Santiago Martin J, et al. Subdural empyema due to Mycoplasma hominis after a cesarean section under spinal anesthesia. Rev Esp Anestesiol Reanim. 2005. 52(4):239-242. [Medline].

  9. Dwarakanath S, Suri A, Mahapatra AK. Spontaneous subdural empyema in falciparum malaria: a case study. J Vector Borne Dis. 2004 Sep-Dec. 41(3-4):80-2. [Medline].

  10. Foerster BR, Thurnher MM, Malani PN, Petrou M, Carets-Zumelzu F, Sundgren PC. Intracranial infections: clinical and imaging characteristics. Acta Radiologica. October 2007. 48(8):875-93. [Medline].

  11. Hall WA, Truwit CL. The surgical management of infections involving the cerebrum. Neurosurgery. February 2008. 62 Supplement 2:519-30. [Medline].

  12. Krauss WE, McCormick PC. Infections of the dural spaces. Neurosurg Clin N Am. 1992 Apr. 3(2):421-33. [Medline].

  13. Mauser HW, Van Houwelingen HC, Tulleken CA. Factors affecting the outcome in subdural empyema. J Neurol Neurosurg Psychiatry. 1987 Sep. 50(9):1136-41. [Medline].

  14. Migirov L, Eyal A, Kronenberg J. Intracranial complications following mastoidectomy. Pediatr Neurosurg. 2004 Sep-Oct. 40(5):226-9. [Medline].

  15. Placeholder.

  16. Moorthy RK, Rajshekhar V. Intracranial Abscess. Neurosurg Focus. 2008. 24 (6):E3.

 
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MRI scan of a subdural empyema in the left parietal area.
CT scan of a subdural empyema in the left temporal/parietal area.
 
 
 
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