Subdural empyema overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]
Overview
Subdural empyema is a life-threatening infection, consisting of a localized collection of purulent material, usually unilateral, between the dura mater and the arachnoid mater. Subdural empyema may be classified according to location of the infection into 2 groups: intracranial and spinal, with intracranial being the more common of the two groups, accounting for 95% of subdural empyema patients.[1][2] Subdural empyema accounts for approximately 15-25% of focal central nervous system infections. In 2014, the incidence of subdural empyema was estimated to be less than 1 case case per 100,000 individuals, with a male predominance.[3] The most common pathogens in intracranial subdural empyema are anaerobic and microaerophilic Streptococci, compared to spinal subdural epmyema, which can be caused by either Streptococci or Staphylococcus aureus.[2] If left untreated, subdural empyema frequently evolves into severe fever, headache, nausea, vomiting, seizures, coma, and subsequent mortality. Complications to subdural empyema include status epilepticus, neurological deficits, and thrombosis. Prognosis is generally good with antimicrobial therapy. Physical examination of patients with subdural empyema is usually remarkable for fever, facial pain, and altered mental status.[4][5][6] MRI is the primary imaging study of epidural abscess, with CT scan as a secondary alternative. Treatment of subdural empyema requires a combined medical and surgical approach. In order to evacuate the pus, burr hole placement or craniotomy may be used to treat the subdural empyema. The preferred surgical mainstay of treatment for subdural empyema is craniotomy.
Historical Perspective
In 1869, subdural empyema was first operated on by François Gigot de la Peyronie.[7] The first attempted detailed description of the disease was by Cyril Brian Courville in 1939.
Classification
Subdural empyema may be classified according to location of the infection into 2 groups: intracranial and spinal.[1][2]
Pathophysiology
Subdural empyema is a localized collection of pus between the dura mater and arachnoid mater, occurring in either the intracranial space or the spinal canal.[8][1][2] Subdural empyema generally follows the same progression for both intracranial and spinal subtypes, spreading via blood or from nearby infection. Bacterial infections of the skull or air sinuses can spread to the subdural space, producing a subdural empyema. The underlying arachnoid and subarachnoid spaces are usually unaffected, but a large subdural empyema may produce a mass effect.
Causes
Common causes of subdural empyema include Streptococci, Staphylococci, and other Gram-negative bacilli.[1] In children, the majority of cases of subdural empyema occur due to meningitis, while in adults the most common causes are sinusitis, otitis media, mastoiditis, and trauma.[1][9]
Differentiating Subdural Empyema from Other Diseases
Subdural empyema must be differentiated from other diseases that cause fever, headache, focal neurological signs, seizures, and altered mental status, such as subdural hematoma, brain abscess, and bacterial meningitis. These conditions may be distinguished from subdural empyema by their clinical findings, brain imaging findings, and laboratory studies.
Epidemiology and Demographics
Subdural empyema consists of a localised collection of purulent material, usually unilateral, between the dura mater and the arachnoid mater and accounts for about 15-22% of the reported focal intracranial infections. The empyema may develop intracranially (about 95%) or in the spinal canal (about 5%), and in both cases, it constitutes a medical and neurosurgical emergency.[2] It usually occurs in infancy and young adults (70% cases occurring in the second and third decades of life), being more frequent in men than women, possibly due to sex-related differences in sinus anatomy. It develops in 39-60% of the cases of pyogenic meningitis, but only in 1-2% of the cases of bacterial meningitis. [10][2] However sinusitis is the most common predisposing condition, typically involving the frontal air sinus alone or concomitantly with ethmoid and maxillary sinuses. Less frequent cases develop as a complication of head trauma or neurosurgical procedures.[11]
Causes
Depending on the site of origin of the infection, as well as location of the empyema in the subdural space, there will be different causative agents. The rate of success of bacterial cultures from the surgically removed pus is 54-81%. Common agents of subdural empyema include: anaerobes, aerobic streptococci, staphylococci, Haemophilus influenzae, Streptococcus pneumoniae and other gram-negative bacilli. [1] In children, subdural empyema happens most often as a complication of meningitis while in adults it usually occurs as a complication of sinusitis, otitis media, mastoiditis trauma or as a complication of neurological procedures.[1][9]
Diagnosis
Symptoms
Symptoms include those referable to the source of the infection.
In the case of infants, common symptoms will include:
In the case of adult patients, common symptoms are
If untreated, may evolve into:
Laboratory Findings
Patients with subdural empyema usually have: [1]
- elevated white blood cell count
- elevated erythrocyte sedimentation rate
- elevated c-reactive protein
Children with hyperglycemia or diabetes have an increased risk of developing sinogenic intracranial empyema.
The CSF profile is similar to that seen in brain abscesses, since both are parameningeal infectious processes: [1]
- increased white blood cell count
- increased protein level
- decreased glucose levels
- occasionally CSF results may be normal
Treatment
Medical Therapy
The clinical symptoms may be mild and unspecific initially. The rapid diagnosis and treatment are crucial, the sooner the proper treatment is initiated, the better the recovery will be. The treatment, for almost all causes, requires prompt surgical drainage (via burr hole procedure or craniotomy) and antibiotic therapy, which should be broad-spectrum initially, and adjusted to the organism, once the results from the drained infected material are know. [2] With treatment, including surgical drainage, resolution of the empyema occurs from the dural side, and, if it is complete, a thickened dura may be the only residual finding.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Agrawal, Amit; Timothy, Jake; Pandit, Lekha; Shetty, Lathika; Shetty, J.P. (2007). "A Review of Subdural Empyema and Its Management". Infectious Diseases in Clinical Practice. 15 (3): 149–153. doi:10.1097/01.idc.0000269905.67284.c7. ISSN 1056-9103.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Greenlee JE (2003). "Subdural Empyema". Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.
- ↑ French H, Schaefer N (2014). "Intracranial Subdural Empyema: A 10-Year Case Series". Oschner J. 12 (2). doi:10.1002/bip.360240911. PMID PMC4052585 Check
|pmid=value (help). - ↑ Hendaus, Mohammed A. (2013). "Subdural Empyema in Children". Global Journal of Health Science. 5 (6). doi:10.5539/gjhs.v5n6p54. ISSN 1916-9744.
- ↑ Bruner DI, Littlejohn L, Pritchard A (2012). "Subdural empyema presenting with seizure, confusion, and focal weakness". West J Emerg Med. 13 (6): 509–11. doi:10.5811/westjem.2012.5.11727. PMC 3555596. PMID 23358438.
- ↑ Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0-443-06839-9.
- ↑ Khan M, Griebel R (1984). "Subdural empyema: a retrospective study of 15 patients". Can J Surg. 27 (3): 283–5, 288. PMID 6144382.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ 9.0 9.1 Quraishi H, Zevallos JP (2006). "Subdural empyema as a complication of sinusitis in the pediatric population". Int. J. Pediatr. Otorhinolaryngol. 70 (9): 1581–6. doi:10.1016/j.ijporl.2006.04.007. PMID 16777239. Unknown parameter
|month=ignored (help) - ↑ Wu TJ, Chiu NC, Huang FY (2008). "Subdural empyema in center". J Microbiol Immunol Infect. 41 (1): 62–7. PMID 18327428. Unknown parameter
|month=ignored (help) - ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.