Subdural Empyema Treatment & Management

  • Author: Segun T Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed); Chief Editor: Karen L Roos, MD   more...
 
Updated: Jul 14, 2011
 

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.

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.[6]

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

  • 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 T Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed)  Associate Professor of Rehabilitation Medicine and Interventional Pain Medicine, Albany Medical College

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

Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Lorenzo, MD  Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants

Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and American College of Physician Executives

Disclosure: Nothing to disclose.

Specialty Editor Board

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, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Florian P Thomas, MD, MA, PhD, Drmed  Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University School of Medicine

Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, and National Multiple Sclerosis Society

Disclosure: Nothing to disclose.

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Karen L Roos, MD  John and Nancy Nelson Professor of Neurology, Professor of Neurological Surgery, Department of Neurology, Indiana University School of Medicine

Karen L Roos, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association

Disclosure: Nothing to disclose.

References

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

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

  3. Brennan MR. Subdural empyema. Am Fam Physician. Jan 1995;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. Aug 1989;32(2):105-10. [Medline].

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

  7. 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].

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

  9. 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].

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

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

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

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

  14. .

  15. [Best Evidence] 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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