Subdural Empyema Follow-up

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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Follow-up

Further Outpatient Care

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  • Outpatient follow-up by the treating medical, surgical, and infectious disease teams is required.
  • A decision needs to be made concerning whether to continue antiseizure prophylaxis. An EEG may be needed to rule out an epileptic focus.
  • Outpatient rehabilitation for physical therapy, occupational therapy, and speech therapy may be needed.
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Further Inpatient Care

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  • Recurrence of subdural empyema requires immediate surgical evacuation. If a burr hole was the initial surgical procedure, a craniotomy flap should be considered.
  • Complications such as seizures and subdural effusion may require more aggressive treatment modalities.
  • Assess and treat residual neurological deficits. Inpatient rehabilitation (either subacute or acute) may be necessary.
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Inpatient & Outpatient Medications

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  • Intravenous antibiotics for a total period of 3-6 weeks can be administered on either an inpatient or outpatient basis.
  • Antiepileptic medication may be indicated.
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Transfer

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  • Transfer to appropriate facilities for medical, surgical, and rehabilitative interventions.
  • Complete, adequate transfer notes with results of all tests and discussion among the physicians are helpful to the receiving institution.
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Complications

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  • Seizures
  • Cavernous sinus thrombosis from septic thrombosis of adjacent cerebral veins
  • Increased intracranial pressure
  • Hydrocephalus from compressed cerebrum resulting in interference with CSF flow
  • Cerebral edema from compressed cerebrum leading to interference with cerebral blood flow
  • Cerebral infarction
  • Cranial osteomyelitis, primarily in adjacent cranial bones
  • Residual neurological deficits (eg, hemiparesis, aphasia)
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Prognosis

The mortality rate gradually is decreasing secondary to more timely diagnosis and intervention (eg, antibiotics, surgical drainage).

Unfavorable prognostic factors

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  • Encephalopathy or coma at the time of presentation
  • Elderly or younger than 10 years
  • Delay in starting antibiotics
  • Sterile cultures

Favorable prognostic factors

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  • Craniotomy as surgical modality (rather than burr holes)
  • Early treatment (surgery and antibiotics)
  • Young age (10-20 y is optimal)
  • Patient alert, awake, and oriented at the time of presentation
  • Paranasal sinus as source of initial infection
  • Isolation of aerobic streptococci in the culture
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Patient Education

Education should emphasize compliance with medication. Urge patients to follow the advice and instructions of rehabilitation programs. The following should be emphasized:

  • The need to complete the full course of antibiotics
  • Regular intake of antiseizure medication, if prescribed
  • A helmet to protect the area of craniotomy
  • Home exercise program

For excellent patient education resources, visit eMedicineHealth's Brain and Nervous System Center and Infections Center. Also, see eMedicineHealth's patient education articles Brain Infection and Antibiotics.

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