Subdural empyema (SDE) is a life-threatening neurological condition that frequently has a rapid and aggressive course. This medical emergency is typically featured by the clinical triad of fever, sinusitis, and neurological deficits. Also, patients experience symptoms such as nausea, emesis, and headache [1], of which the latter is initially characterized as focal but then evolves to generalized. Moreover, the vast majority of patients exhibit meningeal signs such as nuchal rigidity and photophobia. Neurologic signs include hemiparesis, hemiplegia, gait abnormalities, dysphagia, and visual changes. Patients also develop seizures and mental status changes such as confusion, drowsiness, stupor, or even coma.

Complications

Serious outcomes include cerebral edema, cerebral infarction, hydrocephalus, cavernous sinus thrombosis [2], status epilepticus, and fulminant cerebritis [3].

Physical examination

Remarkable findings on the neurologic exam include aphasia, contralateral motor deficits, gait ataxia, and possibly palsies of the oculomotor, trigeminal, and abducens cranial nerves. Ophthalmologic exam shows papilledema, which is reflective of elevated intracranial pressure. An altered mental status is also apparent.

It should be noted that the clinical presentation of subdural empyema closely resembles that of other forms of intracranial infections. Hence, the differential diagnoses are meningitis, viral encephalitis, brain abscess, and cerebritis [4] [5].

• Fever

  We report a 9-month-old female infant diagnosed as Salmonella subdural empyema with clinical features of prolonged fever for more than 2 months and episodic focal seizures. [ncbi.nlm.nih.gov]

  Symptoms of epidural abscess include fever, headache, vomiting, and sometimes lethargy, focal neurologic deficits, seizures, and/or coma. [merckmanuals.com]

  […] influenzae, E coli) Pus along convexities, tentorium, interhemispheric fissure - spread gravity dependent Complications, mortality 10% Venous thrombosis -> fatal in 90% of cases Coritcal infarction Brain abscess CLINICAL PRESENTATION Sinusitis, otitis, fever [learnneurosurgery.com]

• Epilepsy

  The recovery was accompanied by the need for long course of antibiotherapy, secondary epilepsy treatment and kinetotherapy for hemiparesis. [ncbi.nlm.nih.gov]

  FOUNDATION TRUST (2014) Total Damages: £120,000 (£120,233.01 RPI) Trial/settlement date: 1/12/2014 Age at trial: 28 The Claimant, a 28-year-old man, received total damages of £120,000 after he developed a subdural empyema (collection of pus) and subsequent epilepsy [duttongregory.co.uk]

  Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;83-133. With permission from Elsevier ( www.elsevier.com ). [epilepsy.com]

  subdural space Epidural abscess Epidural empyema Subdural abscess ICD-10-CM G06.2 is grouped within Diagnostic Related Group(s) (MS-DRG v 36.0): 023 Craniotomy with major device implant or acute complex cns pdx with mcc or chemotherapy implant or epilepsy [icd10data.com]

• Malaise

  Malaise, fever, and declining mental status can occur rapidly. Complications can include dural venous thrombosis, parenchymal abscess, epidural abscess, and meningitis. Mass effect or secondary venous infarction can cause focal neurologic deficits. [epilepsy.com]

  Fever, a persistent headache, nausea, vomiting and malaise are often reported at the outset, along with symptoms relating to the source of infection. This is not conclusive for a subdural empyema. [healthhype.com]

  The most commonly encountered symptoms of subdural empyema include: Fever, nausea, vomiting, malaise, persistent headache, stiff neck, lethargy, confusion, drowsiness, papilledema, seizures, one sided weakness, abnormal sensation with numbness, blurry [epainassist.com]

• Vomiting

  Symptoms of epidural abscess include fever, headache, vomiting, and sometimes lethargy, focal neurologic deficits, seizures, and/or coma. [merckmanuals.com]

  A 7-year-old girl with an unremarkable medical history presented to a local paediatric emergency department with a 7-day history of fever, sore throat and vomiting, and a 1-day history of rash. [ncbi.nlm.nih.gov]

• Nausea

  Emergency physicians should consider subdural empyema in patients presenting with fever, nausea and headache with worrisome vital signs and laboratory values suggestive of a severe infection. [ncbi.nlm.nih.gov]

  Also, patients experience symptoms such as nausea, emesis, and headache, of which the latter is initially characterized as focal but then evolves to generalized. [symptoma.com]

  The symptoms of subdural empyema are secondary to increased intracranial pressure and include increased temperature, nausea, vomiting, generalised weakness, headache etc. [epainassist.com]

  Fever, a persistent headache, nausea, vomiting and malaise are often reported at the outset, along with symptoms relating to the source of infection. This is not conclusive for a subdural empyema. [healthhype.com]

• Diarrhea

  We report a case of a 9-month-old baby admitted to the hospital because of low-grade fever, focal seizures in a context of watery diarrhea for 14 days' duration. [ncbi.nlm.nih.gov]

• Tachycardia

  There, in addition to fever and tachycardia, reduced consciousness, left-sided hemiparesis, and slight neck stiffness were present. [jcm.asm.org]

• Skin Rash

  We describe a 3-month-old male infant from British Columbia, Canada, who presented on day 5 of varicella skin rash with fever, seizures, lethargy, and evidence of intracranial hypertension. [ncbi.nlm.nih.gov]

  CASE REPORT A 3-month-old boy was admitted to a community hospital, on day 5 of a varicella skin rash, with fever and focal seizures. [pediatrics.aappublications.org]

• Suggestibility

  Empyema should be considered in patients with suspected or proven bacterial menengitis and associated ear nose throat infection with neurological signs that suggest a posterior fossa lesion. [ncbi.nlm.nih.gov]

  Symptoms of subdural empyema include fever, vomiting, impaired consciousness, and rapid development of neurologic signs suggesting widespread involvement of one cerebral hemisphere. [merckmanuals.com]

  Findings on CT scan suggestive of subdural empyema include a crescentic shape, although collection pockets may appear bi-convex. [wikidoc.org]

• Seizure

  Twenty-three patients (82%) presented with neurologic symptoms (paresis, focal seizures, dysesthesia contralateral to the empyema). [ncbi.nlm.nih.gov]

• Headache

  Symptoms of epidural abscess include fever, headache, vomiting, and sometimes lethargy, focal neurologic deficits, seizures, and/or coma. [merckmanuals.com]

  Therefore, these agents should be considered as causes of intracranial infection in persistent complaints such as fever and headache after sinusitis in children. [ncbi.nlm.nih.gov]

• Focal Neurological Deficit

  Symptoms of epidural abscess include fever, headache, vomiting, and sometimes lethargy, focal neurologic deficits, seizures, and/or coma. [merckmanuals.com]

  CONCLUSIONS: Although rare, subdural empyema must be considered in patients with community-acquired bacterial meningitis and otitis or sinusitis, focal neurologic deficits, or epileptic seizures. [ncbi.nlm.nih.gov]

  Symptoms or signs indicative of subdural empyema in adults with meningitis are otitis or sinusitis, focal neurologic deficits, or seizures. [pediatricneurologybriefs.com]

• Lethargy

  We describe a 3-month-old male infant from British Columbia, Canada, who presented on day 5 of varicella skin rash with fever, seizures, lethargy, and evidence of intracranial hypertension. [ncbi.nlm.nih.gov]

  Symptoms of epidural abscess include fever, headache, vomiting, and sometimes lethargy, focal neurologic deficits, seizures, and/or coma. [merckmanuals.com]

• Altered Mental Status

  The most common presenting complaints were fever, headache, altered mental status, orbital cellulitis, nasal symptoms, nausea and vomiting, and photophobia. [ncbi.nlm.nih.gov]

  An altered mental status is also apparent. It should be noted that the clinical presentation of subdural empyema closely resembles that of other forms of intracranial infections. [symptoma.com]

  Clinical manifestations Cranial subdural empyema: fever, headache, altered mental status, symptoms and signs of raised intra-cranial pressure, meningeal irritation or focal irritation. [hkuelcn.med.hku.hk]

  […] the emergency department was subdural hematoma reaccumulation, however, presence of fever and altered mental status were suggestive of infective pathology. [neurologyindia.com]

When evaluating an individual with a clinical picture suggestive of subdural empyema, the medical team should obtain a detailed history including any recent infections such as sinusitis, otitis media, respiratory infection, meningitis, or sinus/cranial surgery. Very importantly, a thorough physical exam must be performed. Finally, diagnostic studies are a crucial component of the workup.

Laboratory tests

Critical studies include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) [6], a complete metabolic panel (CMP), and blood cultures.

Imaging

Magnetic Resonance Imaging (MRI) with gadolinium enhancement is the preferred diagnostic study [1] [7]. The hallmark feature of subdural empyema on MRI is the appearance of a fluid collection surrounded by an enhanced rim. Moreover, MRI with diffusion-weighted imaging will provide information about intra-axial lesions [8]. Overall, MRI is more sensitive than computed tomography (CT) for sinogenic intracranial infections [9].

Historically, CT testing has been considered important for the diagnosis of subdural empyema [10] and is the test of choice in patients with contraindications to MRI, those who are critically ill, or if MRI is not available or possible [11]. CT scan displays subdural empyema as a hypodense region. While nonenhanced CT is insensitive, contrast-enhanced CT improves the diagnostic accuracy.

Other imaging techniques that may be used include cranial ultrasound, radionuclide brain scan, and angiography.

Lumbar puncture

Cerebrospinal fluid (CSF) analysis helps exclude meningitis as the diagnosis. However, lumbar puncture is contraindicated in cases with increased intracranial pressure.

Although they differ somewhat in epidemiology, etiology, pathophysiology, and symptomatology and occur separately, they rarely manifest together. [ncbi.nlm.nih.gov]

The epidemiology, etiology, pathophysiology and symptoms of spinal subdural empyema and cranial subdural empyema are somewhat different, but brain and spinal subdural empyema are not always two different entities. [ncbi.nlm.nih.gov]

EPIDEMIOLOGY sinus infection -> minority subdural empyema 10-40% of intracranial infections 2/3 are 10-40 yo, >Males (esp with increased growth of frontal sinus during puberty) PATHOLOGY Direct spread from frontal* or ethmoid sinus infection (66%, Strep [learnneurosurgery.com]

The epidemiology, pathophysiology, bacteriology, clinical features, radiographic findings and treatment of this life-threatening entity are reviewed. [medschool.lsuhsc.edu]

The epidemiology, etiology, pathophysiology and symptoms of spinal subdural empyema and cranial subdural empyema are somewhat different, but brain and spinal subdural empyema are not always two different entities. [ncbi.nlm.nih.gov]

This case illustrates the importance of universal varicella vaccination to prevent associated bacterial complications of chickenpox. [ncbi.nlm.nih.gov]

He sustained injury and brought an action against the Defendant alleging it was negligent in delaying listing for his surgery which had caused him to suffer a preventable empyema. Liability was admitted. [duttongregory.co.uk]

Treatment includes surgical drainage, antibiotics, and sometimes drugs to prevent seizures or to reduce pressure within the skull. [merckmanuals.com]

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11. Moseley IF, Kendall BE. Radiology of intracranial empyemas with special reference to computed tomography. Neuroradiology. 1984;26(5):333-345.