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Subdural Empyema

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Subdural Empyema
Author: Segun T Dawodu, MD, JD, MBA, LLM, FAAPMR, FAANEM; Chief Editor: Karen L Roos, MD more... Updated: Jul 14, 2011

Background
Subdural empyema (ie, abscess) is an intracranial focal collection of purulent material located between the dura mater and the arachnoid mater. About 95% of subdural empyemas are located within the cranium; most involve the frontal lobe, and 5% involve the spinal neuraxis. This chapter focuses on the intracranial type, which causes clinical problems through extrinsic compression of the brain by an inflammatory mass and inflammation of the brain and meninges. Subdural empyema is a life-threatening infection that was first reported in the literature about 100 years ago. It accounts for about 15-22% of focal intracranial infections. The mortality rate approached 100% before the introduction of penicillin in 1944 and has declined since that time. Because the symptoms might be very mild initially, rapid recognition and treatment are important; the early institution of appropriate treatment gives the patient a good chance of recovery with little or no neurological deficit.

Pathophysiology
Subdural empyema is a primarily intracranial infection located between the dura mater and the arachnoid mater. It has a tendency to spread rapidly through the subdural space until limited by specific boundaries (eg, falx cerebri, tentorium cerebelli, base of the brain, foramen magnum). The subdural space has no septations except in areas where arachnoid granulations are attached to the dura mater. Subdural empyema is usually unilateral. With progression, subdural empyema has a tendency to behave like an expanding mass lesion with associated increased intracranial pressure and cerebral intraparenchymal penetration. Cerebral edema and hydrocephalus also may be present secondary to disruption of blood flow or cerebrospinal fluid (CSF) flow caused by the increased intracranial pressure. Cerebral infarction may be present from thrombosis of the cortical veins or cavernous sinuses or from septic venous thrombosis of contiguous veins in the area of the subdural empyema. In infants and young children, subdural empyema most often occurs as a complication of meningitis. In such cases, subdural empyema should be differentiated from reactive subdural effusion (ie, sterile collection of fluid due to increased efflux of intravascular fluids from increased capillary wall fenestrations into the subdural space). In older children and adults, it occurs as a complication of paranasal sinusitis, otitis media, or mastoiditis.
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Infection usually enters through the frontal or ethmoid sinuses; less frequently, it enters through the middle ear, mastoid cells, or sphenoid sinus. This often occurs within 2 weeks of a sinusitis episode, with the infection spreading intracranially through thrombophlebitis in the venous sinuses. Infection also may extend directly through the cranium and dura from an erosion of the posterior wall of the mastoid bone or frontal sinus. Direct extension also could be from an intracerebral abscess. Rarely, infection spreads hematogenously from distant foci, most commonly from a pulmonary source or as a complication of trauma, surgery, or septicemia. The sphenoid sinus also could be a source of infection.

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. However, otitis media and mastoiditis are the most common predisposing conditions.

Mortality/Morbidity
In the pre-antibiotic era, the mortality rate approached 100%; this still may be the case in developing countries. In the developed world, the mortality rate has improved tremendously: it is about 6-35% (variance depending on areas and hospitals); however, about 55% of patients have neurological deficits at the time of hospital discharge. The mortality rate has continued to decline because of early diagnosis and treatment, more accurate localization with head CT scan, early sinus drainage, and recognition of the prominent role of anaerobes in the disease. The high incidence of morbidity (ie, neurological deficits) is attributed to the short follow-up period and low mortality rate. Very ill patients who would have died in the past now survive with deficits.

Race
No documented race differences have been found, although geographical differences do exist.

Sex
Subdural empyema is more common in males, who can account for up to 80% of cases. The reason for this predominance is unknown. One theory is that the normal development of the paranasal sinuses in males results in anatomic differences that predispose them to recurrent sinusitis.

Age
Subdural empyema can occur at any age, but about two thirds of patients are aged 10-40 years.

Contributor Information and Disclosures

Author Segun T Dawodu, MD, JD, MBA, LLM, FAAPMR, FAANEM Associate Professor of Rehabilitation Medicine and Interventional Pain Medicine, Albany Medical College Segun T Dawodu, MD, JD, MBA, LLM, FAAPMR, FAANEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and
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Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Medical Informatics Association, Association of Academic Physiatrists, International Society of Physical and Rehabilitation Medicine, and Royal College of Surgeons of England Disclosure: Nothing to disclose. Coauthor(s) Nicholas Lorenzo, MD, CPE Chairman and CEO, Neurology Specialists and Consultants; Senior Vice President, Founding Executive Director, Continuing Medical Education, Gannett Education (Division Gannett Healthcare Group) Nicholas Lorenzo, MD, CPE is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and American College of Physician Executives Disclosure: Nothing to disclose. Specialty Editor Board Edward L Hogan, MD Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Florian P Thomas, MD, MA, PhD, Drmed Director, Regional MS Center of Excellence, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, St Louis University School of Medicine Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, and Sigma Xi Disclosure: Nothing to disclose. Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting; Sunovion Consulting fee None Chief Editor Karen L Roos, MD John and Nancy Nelson Professor of Neurology, Professor of Neurological Surgery, Department of Neurology, Indiana University School of Medicine Karen L Roos, MD is a member of the following medical societies: American Academy of Neurology and
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American Neurological Association Disclosure: Nothing to disclose.

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