Subdural Empyema Clinical Presentation

Updated: Nov 27, 2017
  • Author: Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Presentation

History

A patient with subdural empyema could present with any of the following symptoms:

  • Fever - Temperature above 38°C (100.5°F)
  • Headache - Initially focal and later generalized
  • Recent history (< 2 wk) of sinusitis, [1] otitis media, mastoiditis, meningitis, cranial surgery or trauma, sinus surgery, or pulmonary infection
  • Confusion, drowsiness, stupor, or coma
  • Hemiparesis or hemiplegia
  • Seizure - Focal or generalized
  • Nausea or vomiting
  • Blurred vision (amblyopia)
  • Speech difficulty (dysphasia)
  • History of intracerebral abscess (recent or in the past)
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Physical

A patient with subdural empyema may show some of the following signs:

  • Mental status changes - Confusion, drowsiness, stupor, and coma
  • Meningismus or meningeal signs
  • Hemiparesis or hemisensory deficits
  • Aphasia or dysarthria
  • Seizure
  • Sinus tenderness, swelling, or inflammation
  • Papilledema and other features of increased intracranial pressure, such as nausea/vomiting, mental status changes, and gait disturbance
  • Homonymous hemianopsia
  • Palsies of cranial nerves III, V, or VI, especially if the abscess is near a petrous portion of the temporal bone, causing facial pain and lateral rectus muscle weakness
  • Fixed, dilated pupil on the ipsilateral side due to compression of cranial nerve III
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Causes

The most common cause is extension from paranasal sinusitis, especially from the frontal and ethmoidal sinuses. It could also arise as a complication of otitis media, mastoiditis, septicemia, subdural hematoma, [2] cranial trauma or surgery, or recent sinus surgery; by spread or extension from an intracerebral abscess; by hematogenous spread from pulmonary sources; or from septic thrombosis of cranial veins. Common causative organisms are anaerobes, aerobic streptococci, staphylococci, Haemophilus influenzae,Streptococcus pneumoniae, and other gram-negative bacilli.

  • Paranasal sinusitis - Staphylococcus aureus, alpha-hemolytic streptococci, anaerobic streptococci, Bacteroides species, Enterobacteriaceae
  • Otitis media, mastoiditis - Alpha-hemolytic streptococci, Pseudomonas aeruginosa, Bacteroides species, S aureus
  • Trauma, postsurgical infection - S aureus, Staphylococcus epidermidis, Enterobacteriaceae
  • Pulmonary spread - S pneumoniae, Klebsiella pneumoniae
  • Meningitis (infant or child) - S pneumoniae, H influenzae, Escherichia coli, Neisseria meningitidis
  • Neonates - Enterobacteriaceae, group B streptococci, Listeria monocytogenes
  • Others include hematogenous spread from skin postsurgery (eg, abdominal surgery). Spread from a focus of tuberculosis infection could also occur. A case of subdural empyema developing after infection with Plasmodium falciparum malaria.
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