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Subdural Empyema

Subdural empyema is a collection of pus that accumulates in the space between the dura mater and arachnoid mater. This is a life-threatening condition that should be diagnosed and treated urgently. In most cases, it emerges as a complication of paranasal sinusitis or otitis media.


Presentation

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].

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]
Hunting
  • We highlight the difficulties in diagnosing Hunt syndrome and argue the case for early treatment of all patients with Hunt syndrome and Bell's palsy with a combination of systemic steroids and antiviral drugs.[ncbi.nlm.nih.gov]
  • DISCUSSION Although uncommon, neurologic complications of varicella include postinfectious cerebellar ataxia, meningoencephalitis, Reye syndrome, myelitis, optic neuritis, stroke, Guillain-Barré syndrome, seventh cranial nerve palsy, and Ramsay-Hunt syndrome[pediatrics.aappublications.org]
Streptococcal Pharyngitis
  • On hospital day 2, cerebral spinal fluid cultures and blood cultures grew Streptococcus pyogenes, and repeat physical examination was consistent with acute streptococcal pharyngitis.[ncbi.nlm.nih.gov]
  • Streptococcal pharyngitis: an uncommon cause of subdural empyema. BMJ Case Rep. 2015;211312. [ Links ] 19. Giamarellou HJ, Tsagarakis J, Petrikkos G, Mavroudis K, Veldekis D, Daikos GK.[scielo.br]
Gaucher Disease
  • Patients with Gaucher disease may be vulnerable to severe bacterial infections, due to defective function of phagocytic cells and hypersplenism.[ncbi.nlm.nih.gov]
School Problem
  • Persistent disorders at the end of the follow-up period, especially headaches, cognitive, concentration or schooling problems, tended to be more frequent in the SE group than in the EE group (67% vs 29%), and were more commonly observed in cases requiring[ncbi.nlm.nih.gov]
Bulging Fontanelle
  • fontanelle, seizures DIFFERENTIAL Epidural abscess - not as ill, rare nuchal rigidity Cerebral abscess - chronic course, rare nuchal rigidity SDH - no contrast enhancement on CT DIAGNOSIS Fevers, high WBC, ESR, CRP CT w/ contrast: hypodense /- peripheral[learnneurosurgery.com]
  • The rest of the clinical manifestations were described according to the age of our patient, negative nuchal rigidity but bulging fontanelle. It may be for this reason that early symptoms of the subdural empyema were masked by meningitis.[casesjournal.biomedcentral.com]
  • He was irritable during handling, was hyperreflexic, had a bulging fontanelle, and was still under the sedative effects of anticonvulsants.[pediatrics.aappublications.org]
  • Bulging fontanelle in infants. Differential diagnosis Meningitis. Encephalitis. Brain tumour or other intracranial space-occupying lesion. Investigations [ 8, 9 ] FBC: marked leukocytosis. Raised ESR and CRP.[patient.info]
Cerebellar Sign
  • Cerebellar signs were elicited only in 40%. The most common source was untreated middle ear infection. Pus usually accumulates over the cerebellar convexity and is associated with hydrocephalus in 74% of patients.[ncbi.nlm.nih.gov]
  • Cerebellar signs were found only in 21% of patients. In 85.7% of the cases, the patients presented with a depressed level of consciousness (Glasgow Coma Scale Scores 11-15).[ncbi.nlm.nih.gov]
  • This is particularly true in cases of infratentorial subdural empyema that occurs infrequently, but that is easily suspected if cerebellar signs such as ataxia and nystagmus are present ( 27 ).[oncohemakey.com]
Neglect
  • Empyema was diagnosed with serial follow-up computed tomography and magnetic resonance imaging while he was being treated for bacterial meningitis secondary to neglected mastoiditis.[ncbi.nlm.nih.gov]
  • We briefly describe the case of a 49-year-old man presented with severe debility, fever and an obviously neglected chronic otitis media. The patient had refused surgical treatment several months ago.[ncbi.nlm.nih.gov]
Gait Ataxia
  • 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.[symptoma.com]

Workup

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.

Clostridium Perfringens
  • We report a clinical case of meningoencephalitis with subdural empyema in an immunocompromised farmer caused by toxigenic Clostridium perfringens type A, which was identified by 16S RNA gene analysis of cerebrospinal fluid and subdural empyema.[ncbi.nlm.nih.gov]
Ischemic Changes
  • Ischemic changes were also shown in the right cerebellar hemisphere and brainstem.[ncbi.nlm.nih.gov]

Treatment



Prognosis

Etiology

  • Although they differ somewhat in epidemiology, etiology, pathophysiology, and symptomatology and occur separately, they rarely manifest together.[ncbi.nlm.nih.gov]
  • Predisposing factors and etiological agents may change with time. This study examined the epidemiological features of these conditions.[ncbi.nlm.nih.gov]
  • The prevalence, etiology, clinical features, investigations and management of SDE are reviewed in this article.[ncbi.nlm.nih.gov]
  • Etiologies of spinal subdural empyema include hematogenous spread from skin lesions, systemic sepsis, direct spread from spinal osteomyelitis and complications of discography.[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

  • 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]
  • Although they differ somewhat in epidemiology, etiology, pathophysiology, and symptomatology and occur separately, they rarely manifest together.[ncbi.nlm.nih.gov]
  • This study examined the epidemiological features of these conditions. METHODS: The medical records of all inpatients with a diagnosis of brain abscess or subdural empyema from 1998 to 2007 were reviewed.[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]
  • Epidemiology Frequency United States Subdural empyema accounts for 15-22% of focal intracranial infections. Sinusitis is the most common predisposing factor in the developed world. International Frequency is similar to that in the Unites States.[emedicine.com]
Sex distribution
Age distribution

Pathophysiology

  • 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 study reviews the pathophysiology of subdural empyema and illustrates its potential neuropsychological impact to inform clinicians encountering this rare condition.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Subdural empyema due to meningitis in infants is unique with respect to the pathophysiology, presentation, and treatment of SDE. Early detection and removal of SDE provide a favorable outcome in both surgical intervention groups.[ncbi.nlm.nih.gov]
  • Although they differ somewhat in epidemiology, etiology, pathophysiology, and symptomatology and occur separately, they rarely manifest together.[ncbi.nlm.nih.gov]
  • We present a series of 10 patients where we have attempted to describe the pathophysiology, clinical features, and management of subdural empyema. The study group included 10 cases of falcotentorial subdural empyemas managed between 2004 and 2010.[ncbi.nlm.nih.gov]

Prevention

  • The 7F strain is not contained in PCV7 (the only vaccine on the market at the time of the onset of meningitis) but is included in the new pediatric 13-valent PCV, which may therefore prevent cases such as this in the future.[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]
  • The empyema will also irritate the cortex a great deal, and dilantin can both prevent and control resultant seizure activity.[medschool.lsuhsc.edu]

Summary



References

Article

  1. Greenlee JE. Subdural empyema. Curr Treat Options Neurol. 2003;5(1):13-22.
  2. Agrawal AM, Timothy J, Pandit L, Shetty L, Shetty JP. A Review of Subdural Empyema and Its Management. Infect Dis Clin Prac. 2007;15(3)149-153.
  3. Stephanov S, Joubert M, Welchman JM. Combined convexity and parafalx subdural empyema.Surg Neurol. 1979;11(2):147-151.
  4. Renaudin JW, Frazee J.Subdural empyema--importance of early diagnosis. Neurosurgery. 1980;7(5):477-9.
  5. Singh B, Van Dellen J, Ramjettan S, Maharaj TJ. Sinogenic intracranial complications. J Laryngol Otol. 1995; 109(10):945-50.
  6. Adame N, Hedlund G, Byington CL. Sinogenic intracranial empyema in children. Pediatrics. 2005;116(3):461-467.
  7. Younis RT, Anand VK, Davidson B. The role of computed tomography and magnetic resonance imaging in patients with sinusitis with complications. Laryngoscope. 2002;112(2):224-229.
  8. Chang SC, Lai PH, Chen WL, et al. Diffusion-weighted MRI features of brain abscess and cystic or necrotic brain tumors: comparison with conventional MRI. Clin Imaging. 2002;26(4):227-236.
  9. Germiller JA, Sparano AM. Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg. 2006;132(9):969–976.
  10. Weingarten K, Zimmerman RD, Becker RD, et al. Subdural and epidural empyemas: MR imaging. Am J Neuroradiol. 1989;10:81-87.
  11. Moseley IF, Kendall BE. Radiology of intracranial empyemas with special reference to computed tomography. Neuroradiology. 1984;26(5):333-345.

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Last updated: 2019-06-28 11:55