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PubMed2003

Subdural Empyema.

Subdural empyema represents loculated infection between the outermost layer of the meninges, the dura, and the arachnoid. The empyema may develop intracranially or in the spinal canal. Intracranial subdural empyema is most frequently a complication of sinusitis or, less frequently, otitis or neurosurgical procedures. Spinal subdural empyema is rare and may result from hematogenous infection or spread of infection from osteomyelitis. The most common organisms in intracranial subdural empyema are anaerobic and microaerophilic streptococci, in particular those of the Streptococcus milleri group (S. milleri and Streptococcus anginosus). Staphylococcus aureus is present in a minority of cases, and multiple additional organisms, including Gram-negative organisms, such as Escherichia coli, and anaerobic organisms, such as Bacteroides, may be present. Pseudomonas aeruginosa or Staphylococcus epidermidis may be present in cases related to neurosurgical procedures, and Salmonella species have been detected in patients with advanced AIDS; multiple organisms may be present simultaneously. Spinal subdural empyemas are almost invariably caused by streptococci or by S. aureus. Subdural empyema--whether it occurs in the skull or the spinal canal--may cause rapid compression of the brain or spinal cord, and represents an extreme medical and neurosurgical emergency. The diagnostic procedure of choice for intracranial and spinal subdural empyema is MRI with gadolinium enhancement. Computed tomography scan may miss intracranial subdural empyemas detectable by MRI. Conversely, occasion spinal subdural empyemas may be detected by CT myelography where MRI is negative. Treatment in virtually all cases of intracranial or spinal subdural empyema requires prompt surgical drainage and antibiotic therapy. Pus from the empyema should always be sent for anaerobic, as well as aerobic, culture. Because intracranial subdural empyemas may contain multiple organisms, provisional antibiotic therapy of intracranial subdural empyema, where the organism is unknown, should be directed against S. aureus, microaerophilic and anaerobic streptococci, and Gram-negative organisms. Antibiotics should include 1) nafcillin, oxacillin, or vancomycin; plus 2) a third generation cephalosporin; plus 3) metronidazole. Provisional antibiotic therapy of spinal subdural empyemas should be directed against S. aureus and streptococci, and should include nafcillin, oxacillin, or vancomycin. Morbidity and mortality in intracranial and spinal subdural empyema relate directly to the delay in institution of therapy. Both conditions should, thus, be treated with great urgency.

Journal Article↗
PubMed1987

The use of neuropsychological evaluation in the medical management of subdural empyema.

Subdural empyema is in itself an uncommon complication of infection in childhood and localization of the infection to the parafalcine area is rare. This paper presents a case study of a teenager with subdural empyema resulting from paranasal sinusitis, who presented as a parafalcine syndrome and was treated successfully without neurosurgical intervention. Results of repeat neuropsychological evaluation (premorbid, 17 days into treatment, and after six months), correlated with changes seen on serial CT scanning during treatment and follow up. More importantly, the neuropsychological evaluation was clinically more sensitive than the traditional neurological examination in assessing changes in cortical integrity during the course of recovery. Thus, neuropsychological evaluation proved to be a valuable supplement to the neurological examination in exploring morbidity and assisting in treatment decision making in the management of subdural empyema.

Journal Article↗
PubMed1976

Angiographic features of subdural empyema.

Subdural empyema, a relatively rare intracranial suppurative disease, is a surgical emergency and requires early diagnosis in order to ensure patient survival. Subdural empyema should be considered with one or a combination of the following in conjunction with an extracerebral collection: (a) an irregular border of the extracerebral collection; (b) a thickened vascular wall of dura; (c) a semilunar avascular zone on the lateral view; (d) spasm of the large arteries at the base of the brain with or without segmental arterial dilatation; (e) multiple peripheral arterial occlusions; and (f) enlargement of the anterior falx artery. Four verified cases are presented.

Adult↗
PubMed1989

[Subdural empyema].

Subdural empyema is a rare, but severe complication after skull-brain trauma and/or sinusitis. On the basis of four of our own cases the symptomatology, diagnostic problems and therapeutical management are discussed. Therapy should be an enlarged burr-hole trepanation or--if thick membranes develop--craniotomy and drainage of the empyema cavity. The use of modern CNS-penetrating antibiotics has canaed previously high mortality to decrease impressively.

Adult↗
PubMed1986

Mixed bacterial subdural empyema complicating subdural peritoneal shunt.

Bilateral subdural empyema occurred in a nine-month-old boy with a subdural-peritoneal shunt. Because of the mixed composition of bacterial growths, representative of faecal flora, it is assumed that the infection originated from perforation of the bowel by the distal tip of the shunt catheter, although no abnormal abdominal signs or symptoms were noted.

Anti-Bacterial Agents↗
PubMed2002

Bifrontal decompressive craniectomy for acute subdural empyema.

INTRODUCTION: Subdural empyema is an uncommon but serious complication of sinusitis. Despite the use of advanced imaging facilities, modern antibiotic therapy and aggressive neurosurgical protocols, this condition still carries significant morbidity and mortality. CASE REPORT: We report an unusual case of sinusitis-associated acute subdural empyema in a 13-year-old patient, presenting in a catastrophic manner with acutely raised intracranial pressure. Emergency bifrontal decompressive craniectomy was necessary both to reduce the intracranial pressure and to drain the subdural empyema. RESULTS: The full range of intracranial complications subsequently occurred, including brain abscesses, recurrent subdural empyema and ventriculitis. Despite this, the patient's outcome was good, with minimal intellectual deficits. CONCLUSION: In cases of severe intracranial infection, we therefore advocate an aggressive surgical approach coupled with appropriate antibiotics to ensure a good outcome.

Acute Disease↗
PubMed1990

[Subdural empyema].

The subdural empyema is a severe inflammatory cerebral affection and shows some diagnostic and therapeutic problems. Extracerebral infections especially in the rhinogenous and otogenic region represent the most frequent cause of the subdural empyema. Seven cases, treated between 1982 and 1986 in our department, are the base to discuss the problems of symptomatology, differential diagnosis and therapy. The treatment of choice is a sudden craniotomy in combination with a through-drainage and administration of antibiotics.

Adolescent↗
PubMed1981

"Subacute" postoperative subdural empyema.

Although subdural empyema (SDE) has long been a recognized postoperative complication, little has been written to suggest that SDE's following operative procedures are different from those occurring in patients who have not had previous surgery. Four cases of postoperative SDE are reported which seem to have several distinguishing features and are grouped under the title of "subacute" subdural empyemas. These include: occurrence in a previous craniotomy site, a prolonged course, the insidious onset of symptoms, and the absence of signs of constitutional illness. The presence of an inner subdural membrane which limits the size of the empyema and separates it from the underlying brain is thought to be the reason for the relatively benign nature of the presenting symptoms and the extremely good prognosis. Computerized tomography scanning was not able to provide a preoperative diagnosis of empyema in any case.

Acute Disease↗
PubMed1989

Omentum graft for intractable subdural empyema.

A subdural empyema developed in a young man after craniotomy for evacuation of a hematoma in a sylvian fissure arachnoid cyst and the subdural space. Despite prolonged systemic and subdural antibiotic administration and a debridement of the subdural space, infection persisted, as evidenced by persistent fever, an elevated white blood cell count, and an extremely low cerebrospinal fluid glucose level. The infection was cured after a second debridement operation where microsurgically revascularized free omentum was used to obliterate the cyst and to cover the cerebral hemisphere in the craniotomy defect. The use of vascularized free omentum may prove useful in cases of refractory cranial wound infection and cerebrospinal fluid fistulas.

Adolescent↗
PubMed1998

[A case of Salmonella subdural empyema developed in chronic subdural hematoma].

A case of Salmonella subdural empyema developed in chronic subdural hematoma (Infected Subdural Hematoma; ISH) was reported. A 64-year-old man had been in a nearby hospital due to myelodysplastic syndrome with cerebral infarction for two months. His condition there had been almost uneventful. But spike fever occurred and the patient became drowsy two days before his transfer to our medical center. His consciousness level deteriorated progressively and CT scan showed a right chronic subdural hematoma. He had had no history of head trauma in the previous two months. On admission to our center, his consciousness level was semicoma with anisocoria. An emergency operation was performed via a single burr hole initially. From the burr hole, old bloody fluid accompanied by yellowish pus was obtained. Thus so-called ISH was diagnosed and the craniotomy was carried out. Gram stain of the specimen revealed gram negative rods. Although an epileptic state developed after the operation, it was controlled by barbiturate coma therapy for 3 days, followed by phenytoin administration. Fever subsided gradually with antibiotics sensitive to the bacteria and his anisocoria disappeared on the 4th postoperative day. In this case, Salmonella enteritidis was detected from bacterial culture both of the specimen and of the arterial blood. Salmonella enteritidis might have been implanted on the capsule of the chronic subdural hematoma by bacteremia derived from immunological dysfunction due to myelodysplastic syndrome. In conclusion, the possibility of ISH should be considered in chronic subdural hematoma patients with immunological dysfunction.

Chronic Disease↗
PubMed1987

Subdural empyemas in children.

Subdural empyema is a neurosurgical emergency which is rapidly fatal if not recognized and managed promptly. Most series report a 30-40% mortality, and recommend a craniotomy along with aggressive medical therapy. Between 1978 and 1986, 8 children (2 months to 13 years) with subdural empyemas were diagnosed and treated at our institution, and form the basis for this study. Burr hole and catheter drainage was the treatment of choice in 5 children, while craniotomy was required in 1 case of sinusitis with osteomyelitis. Three infants received multiple subdural taps via the anterior fontanel. All patients responded to surgical intervention and antibiotic therapy. The average follow-up period was 29 months, and 5 children had no developmental delay, decrease in school performance, or impairment of intellectual function. There were no deaths in our series. Although the surgical management of subdural empyemas remains controversial, it appears that burr hole and catheter drainage is sufficient in most cases. With earlier diagnosis, aggressive antibiotic therapy, and timely surgical intervention, the morbidity and mortality of subdural empyemas have significantly diminished in recent years.

Adolescent↗
PubMed1979

Nonsurgical treatment of interhemispheric subdural empyemas.

Interhemispheric subdural empyema complicating sinusitis was diagnosed in two children by CAT scan. One of them presented with intracranial hypertension and paresis of one foot (syndrome of the falx cerebri). Antibiotic treatment alone without surgery (in one case with brief initial steroid therapy) brought rapid and complete clinical and radiological cure. A nonsurgical approach can now be considered in certain cases of intracranial local suppurations, given the possibility of earlier and more precise initial diagnosis and follow-up with CAT scan.

Adolescent↗
PubMed1996

Treatment of subdural empyema by burr hole.

Subdural empyema, a collection of pus in the space between the dura and arachnoid, is a rare type of intracranial infection. We report on 23 patients, aged 8 months to 70 years, with subdural empyema who were treated in our clinic between 1989 and 1994. The sources of subdural empyemas were meningitis in five patients, middle ear in five, trauma in four, paranasal sinus in three, complications of surgery and subdural tap in four, and unknown in two patients. The common presentations were headache, focal neurologic deficit, fever, vomiting, seizures, and neck stiffness. Diagnosis was achieved by computerized tomography and neurologic examinations in all cases. Treatment was effected by burr hole or small craniotomy with catheter drainage, and antibiotics were administered to all patients. The mortality rate was 8.7%; the remaining patients made a good recovery without sequelae. We therefore recommend burr hole with catheter drainage plus antibiotics as a method of treating subdural empyema.

Adolescent↗
PubMed2000

An unusual subdural empyema: case report.

Subdural empyema in a 38-year-old patient with congenital hemangioma, suppurative parotitisis, soft tissue phlegmonia and osteomyelitis is reported. The clinical, radiological and surgical features are outlined. A review of the literature reveals the uniqueness of this case.

Adult↗
PubMed1989

Interhemispheric empyema. An unusual form of subdural empyema.

A 16 year old male was admitted with a clinical picture suggesting an intracranial pyogenic infection. He also has focal convulsions and left abducens palsy. CT scan showed a subdural empyema with interhemispheric extension. Since the patient was improving clinically, neurosurgical intervention was deferred. Spontaneous interhemispheric empyema is an uncommon condition. In our case conservative management was curative in what is considered a neurosurgical emergency.

Adolescent↗
PubMed2006

[Subdural empyema secondary to sinusitis].

Subdural empyema is a rare complication of sinusitis in children. Its clinical presentation represents a neurosurgical emergency and as a scarcely recognized entity a delayed diagnosis rapidly increases its fatal prognosis. We report the clinical and radiological course of an adolescent with a subdural empyema secondary to sinusitis. Clinical and radiological features, laboratory findings and outcome of this condition are discussed based in a review of previously reported cases.

Child↗
PubMed1989

Epidural abscess and subdural empyema.

Epidural abscess and subdural empyema are serious intracranial infections that result in significant morbidity and mortality. Frequently, they are secondary to sinusitis or middle ear disease, and the bacteria involved are inhabitants of the upper respiratory tract. Symptoms may be mild and mimic the symptoms of the underlying infection. However, especially with subdural empyema, alteration in the level of consciousness and focal neurologic deficits are common. Morbidity and mortality are minimized by early diagnosis, which is best made with computed tomography scanning, and proper therapy, which consists of surgical drainage and administration of appropriate antimicrobials. It is important that primary care physicians be aware of the clinical features of these potentially fatal complications of common infections.

Adolescent↗
PubMed1999

Sinogenic subdural empyema and Streptococcus anginosus.

Subdural empyema (SDE) is most commonly caused by sinusitis and, without early diagnosis and neurosurgical intervention, is associated with high mortality. In a patient with sinusitis who presents with mental status changes, the diagnosis of SDE should be suspected on clinical grounds, even in the absence of significant computed tomographic findings. Computed tomography with contrast is a useful aid in the diagnosis of SDE, but findings may be subtle, and contrasted magnetic resonance imaging is superior. The association of Streptococcus anginosus sinusitis and related intracranial sequelae is important owing to the potentially catastrophic complications and should be recognized by otolaryngologists. In view of the rapidly progressing nature of sinogenic SDE, physicians should strongly consider early institution of aggressive therapy consisting of craniotomy with concurrent sinus drainage in patients in whom sinogenic SDE is suspected on clinical grounds, particularly in the presence of S. anginosus-positive sinus cultures.

Adolescent↗