Child's Nervous System

https://doi.org/10.1007/s00381-018-3907-6

SPECIAL ANNUAL ISSUE

Subdural empyema in children

Dattatraya Muzumdar 1 & Naresh Biyani 2 & Chandrashekhar Deopujari 2

Received: 3 July 2018 / Accepted: 6 July 2018

# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Background Subdural empyema denotes the collection of purulent material in the subdural spaceand is commonly seen in infants
and older children. In infants, the most common cause is bacterialmeningitis. In older children, sinusitis and otitis media are
usually the source for subdural empyema. Theclinical symptomatology is varied and has a wide range including prolonged or
recurrent fever, seizures,meningeal irritation, and raised intracranial pressure. It can mimic as well as complicate meningitis and
aheightened clinical awareness is therefore paramount.
Aims and Objectives The clinical profile, etiopathogenesis, imaging features and management of subdural empyema in children
is discussed and the relevant literature is reviewed.
Conclusion Subdural empyema is a neurosurgical emergency and rapid recognition and treatment canavoid life-threatening
complications. In most cases, surgical decompression through burr hole or craniotomyis warranted. Near complete evacuation
of the purulent material and appropriate long-term intravenous antibiotics are necessary for a gratifying outcome.

Keywords Burr hole . Craniotomy . Empyema . Pediatric . Subdural

Introduction Iatrogenic factors such, as trauma, subdural hematoma drain-

Subdural empyema (SDE) is usually referred to as collection
of purulent material between the intracranial dura and arach-
noid. The first case of subdural empyema in literature was
operated by De la Peyronie upon a patient of SDE secondary
to head injury in 1699. It was reported 10 years later [1].
Kubik and Adams [2] introduced the term BSubdural
Empyema.^ It was earlier known by different names, viz.,
pachymeningitis interna, purulent pachymeningitis, cortical
abscess, and subdural abscess [1]. It manifests predominantly
in infants and older children. Meningitis is the most common
cause in infants while sinusitis and otitis media are the main
source of infection in older children. The incidence is 1–2% of
patients with bacterial meningitis [3–5]. Involvement of the
paranasal sinuses is seen in frontal, ethmoid, sphenoid, and
maxillary sinuses, the most common being the frontal sinus.
* Dattatraya Muzumdar
dmuzumdar@hotmail.com
1
Department of Neurosurgery, King Edward VII Memorial hospital,
Parel, Mumbai 400012, India
2
Department of Pediatric Neurosurgery, Bai Jerbai Wadia hospital for
Children, Parel, Mumbai, India
age, craniotomy, and intracranial pressure monitoring are also
described [4]. Empyema can evolve secondarily in patients
who have soft-tissue infection, intracranial abscess, osteomy-
elitis, or extradural collection. Supratentorial compartment is
the common location, seen usually in the convexity and inter-
hemispheric region. Infratentorial and spinal regions are com-
mon [6–9]. Diagnosis is reasonably confirmed by a quick
contrast-enhanced computed tomography (Fig. 1). It is a life-
threatening condition [3]. Rapid recognition of the disease is
important along with appropriate broad-spectrum intravenous
antibiotic administration. Prompt neurosurgical attention is
required to reduce morbidity and mortality [6–9]. The mortal-
ity rate is approximately 4%. The morbidity includes
hemiparesis in 15 to 35% and persistent seizures in 12 to
37.5% [10].
The management of patients with subdural empyema is
initiated with broad-spectrum intravenous antibiotics.
Surgery is advised in cases with focal neurological deficits,
altered mentation, and absent/inadequate response to antibi-
otics. Usually an adequate sized craniotomy is needed for
complete evacuation of the empyema. This also helps in the
decompression of the underlying cerebral hemisphere. Burr
hole evacuation can be considered if the patient is in septic
shock, poor general condition, medically unfit, or in emergen-
cy situations for rapid decompression.

Fig. 1 A 6-month-old male child, preterm delivery at 36 weeks, pyogenic
meningitis at age of 6 weeks had macrocephaly and raised intracranial
pressure. MR imaging showed bilateral frontoparieto-temporal subdural
empyema, more on the right side associated with mass effect. Multiple
Etiopathogenesis
Pathophysiology
The rapid clinical deterioration seen in cases of subdural empy-
ema has been attributed to toxins produced by bacterial metab-
olism, which can have a direct effect on neural and glial function
[11]. Cerebral venous thrombosis leading to venous obstruction,
stasis, and infarction can be another cause [12–15]. The most
common cause of subdural empyema in the very young is pyo-
genic meningitis leading to subdural infection during the course
of treatment or occasionally after completion of treatment. In
older children, it usually follows chronic otitis media or
pansinusitis. In both these conditions, the common denominator
is a progressive thrombophlebitis, which spreads through the
mucosal veins to emissary veins. Since the emissary venous
network is valveless, it allows subdural spread to occur. The
location of the subdural space is determined by the point of
origin, gravity, and anatomical barriers. The falx and tentorium
tend to limit spread to an area over one hemisphere (Fig. 2).
Tuberculous subdural empyema is even rare [16–18]. There
are few reports in the literature. It results from a hematogenous
Childs Nerv Syst
septations are seen within the subdural cavity. a Axial T2-weighted im-
age. b Axial Flair T1-weighted image. c Sagittal T1-weighted contrast
image. d Axial T1-weighted contrast image. e Coronal T1-weighted con-
trast image
spread of tuberculous bacilli from lung to subdural space
forming a small subpial tuberculous granuloma, which ruptures,
into the adjacent subarachnoid space. The focal rupture can
spread in a diffuse manner due to a large subdural space, e.g.,
interhemispheric collection. The duramater and arachnoid pre-
vent further extension into the epidural space or the calvarium.
Spontaneous subdural empyema following falciparum malaria
is also reported [19] (Fig. 3).
Microbiology
The organisms causing subdural empyema correlate with the age
of the patient and the source of infection. Sometimes more than
one organism is isolated from a single source of infection. In
neonates, the most common organisms causing subdural empy-
ema due to meningitis are Enterobacteriaceae, group B strepto-
cocci or Listeria monocytogenes while in older children H. influ-
enza, Escherichia coli, S. pneumoniae, or Neisseria meningitides
are common. Paranasal sinuses usually harbor alpha-hemolytic
streptococci, anaerobic streptococci, non-hemolytic streptococci,
S. aureus, Bacteroides species, and Enterobacteriaceae and in
otitis media, alpha-hemolytic streptococci, P. aeruginosa,
Childs Nerv Syst
Fig. 2 Eleven-year-old female children, presented with fever and signs of
raised intracranial pressure. CT showing left parietooccipital subdural
empyema, extending into posterior interhemispheric subdural space.
Pus grew E. coli on culture. a Coronal plain CT image. b Axial contrast
CT image at the level of tentorium. c Axial contrast CT image at the level
of the posterior interhemispheric region
Fig. 3 A-5-month-old male child, post hemophilus influenzae meningitis
developed fever and irritability after 2 weeks of treatment. Contrast CT
showed bilateral fronto-parietal subdural empyema, more on the left side.
It extended into the interhemispheric space. a Axial contrast CT image
showing bilateral frontoparietal subdural empyema. b Axial contrast im-
age showing extension of the subdural empyema into the interhemispher-
ic space
Bacteroides species, and S. aureus are commonly isolated.
Streptococcus pueumoniae, followed by group B Streptococcus
(12.9%), Haemophilus influenzae type b (12.9%), Salmonella
(12.9%), Escherichia coli (9.7%), and Pseudomonas aeruginosa
(9.7%) are commonly seen in subdural empyema [20].
Clinical profile
The clinical symptomatology in subdural empyema can be
subtle, and a high index of suspicion is necessary for early
diagnosis and facilitation of prompt treatment. In any child
who appears disproportionately ill in comparison to CSF fea-
tures and has focal neurological signs, subdural empyema

should be ruled out. Infants and young children with SDE
might present with altered mental status, meningeal irritation,
and/or signs and symptoms of intracranial pressure. Seizure is
the primary manifestation in 40% of patients [4]. Older chil-
dren can present with symptoms of primary pathology, name-
ly sinusitis or otitis, viz., fever, headache, photophobia, puru-
lent rhinorrhea, and painful paraesthesiae over the face.
Diagnosis
Routine laboratory studies will usually demonstrate leukocy-
tosis with shift to the left, elevated erythrocyte sedimentation
rate (ESR), and C-reactive protein (CRP). Blood cultures may
or may not reveal an organism [4]. If CSF is obtained, there
will usually be a moderate pleocytosis with an elevated pro-
tein. Commonly, gram stain will not demonstrate any organ-
isms, and CSF cultures are negative. Latex agglutination test
could identify the microorganism [21]. The diagnosis of sub-
dural empyema is mainly based on the clinical presentation,
but imaging is mandatory for a complete work-up.
Cranial sonography in infants can differentiate subdural em-
pyema from subdural effusion [3, 22]. It will appear crescentic in
shape over the cerebral convexity or along the falx with a sur-
rounding hyperdense rim. It is especially useful in patients who
are comatose or critically ill. Trans-fontanelle ultrasonography
can diagnose infantile subdural empyema without any financial
implications, especially in resource-challenged areas [23].
Plain skull and sinus radiographs can reveal a skull fracture,
opacification of sinuses, osteomyelitis, or a lodged foreign body
or diastasis of the sutures in an infant [24]. A high-resolution
contrast enhanced CT scan with bone cuts, axial, and a coronal
plane is usually the investigation of choice [25]. It is easily avail-
able, quick, relatively cheap, and effective in the diagnosis of
subdural empyema. Sometimes in the early stage of the disease,
the CT scan may be normal in up to 50% in patients with SDE or
show only non-specific hemisphere swelling and minimal mid-
line shift [26, 27]. Parafalcine collections are easily missed [28].
It will show crescentic or lentiform extra-axial hypodense col-
lections with prominent, sharp medial rim enhancement.
Enhancement of the adjacent cerebral cortex may also be seen.
In the infratentorial subdural empyema, thin sections (slice width
5 mm or less) with spiral acquisition along with reconstructed
images (coronal reconstruction) are useful in delineating the em-
pyema. It also gives a clear delineation of the bony anatomy of
the paranasal sinuses or petrous bone and the mastoid air cells.
Contrast-enhanced MRI has sensitivity of 93%. It is supe-
rior to CT in defining the extent of subdural collections in
multiple planes and signs of meningeal infection [29]. It
shows a low signal on T1-weighted sequences and a high
signal on T2-weighted sequences. Diffusion-weighted imag-
ing (DWI) is helpful in assessing intraaxial involvement and
also monitoring of antibiotic therapy [30]. In the posterior
Childs Nerv Syst
fossa, it helps to diagnose sinus thrombosis or underlying
cerebellitis or incipient abscess [7]. CISS-3D sequences will
demonstrate any loculi or septae within the empyema, which
can occasionally be dealt with by endoscopic intervention.
Management
The management of subdural empyema depends on a combination
of factors including the clinical symptomatology, duration, extent,
and location of the disease as well as imaging features [31]. Early
diagnosis facilitates prompt institution of treatment. As soon as di-
agnosis is confirmed, medical treatment is commenced and the need
for simultaneous surgical intervention is assessed.
Medical treatment
Intravenous broad-spectrum antibiotics, viz., oxacillin plus
ceftriaxone/cefotaxime plus metronidazole is instituted.
Intravenous route is preferred in the initial 2 weeks, followed
by 6 weeks of oral therapy. The decision to switch to oral med-
ications should be based on the patient’s neurologic status, the
absence of fever, and evidence by CT or MRI of resolution of the
collection [3, 24]. There are no specific guidelines for optimal
duration for the treatment. Antibiotic therapy should continue for
a total of 4 to 6 weeks. The total duration of therapy is usually for
6 to 8 weeks, of which intravenous therapy can be administered
for 2 to 6 weeks followed by oral therapy for the remainder
duration [4, 11]. Broad-spectrum antibiotic regimens and dura-
tion of therapy vary according to the severity of neurological
exam and radiological profile. The antibiotic regimen is also
tailored as per the cultures taken at the time of surgery. In
methicillin-resistant S. aureus, vancomycin is preferred instead
of oxacillin [4]. Linezolid or Targocid can be an alternative anti-
biotic in case of conventional antibiotic regimen failure [24, 32].
Intravenous steroids have been suggested which will help
reduce the edema, swelling, and inflammation [32].
Prophylactic anti-seizure medication is advocated during the
acute phase and is continued later depending upon clinical con-
dition [29]. Intravenous fluids and electrolytes are maintained to
ensure normovolemia.
Anti-seizure medication is advisable since pus in the subdural
cavity can trigger epilepsy. It is usually given only during the
acute phase of disease [11, 29]. In case of prior history of sei-
zures, it is discontinued once the patient is seizure free for at least
2 years [11, 24, 29]. In event of persistent seizures, it is admin-
istered for an indefinite period. The duration of antiseizure med-
ication is also variable.
Conservative or nonoperative management is indicated in pa-
tients who are otherwise well preserved, have non-focal neuro-
logical impairment without alteration of sensorium, thin collec-
tion of empyema, localized lesions except in the posterior fossa
Childs Nerv Syst

and if the response to antibiotics is adequate [33, 34].

Conservative management has its own disadvantages. The long
course of therapy, its consequent financial burden, lack of knowl-
edge about the organism and its sensitivity, and rigid monitoring
of the patient with frequent imaging may be a limitation for its
continuation.

Surgical therapy

Percutaneous needle aspiration through the open fontanelle in

infants or twist drill hole aspiration in children still remains a
preferred first modality of treatment [35, 36]. It can be done
satisfactorily with low recurrence rates and low mortality
rates, thus saving cost and surgical time. Majority of culture
results are organism-negative and broad-spectrum antibiotics
are effective in providing satisfactory antibacterial cover.
The main advantage of surgical management is the ability
to obtain the identity and sensitivity of the causative organ-
isms and institution of appropriate antibiotics. Failure of initial
medical management remains an indication for surgery.
Various surgical options include craniotomy, burr hole evacu-
ation, and endoscopic evacuation.
Craniotomy ensures complete evacuation of the empyema,
especially in the interhemispheric, parafalcine, and infratentorial
regions [6, 12, 24, 32, 37–40]. It can also provide decompression
of the underlying cerebral hemisphere. It is preferred in cases
who are likely to have multiloculated thick pus. Some recom-
mend large craniectomy or tailoring the craniectomy to the site of
the empyema (Fig. 4). Banerjee et al. described 65 pediatric
patients with supratentorial subdural empyema and recommend
an early surgical drainage, preferably craniotomy, eradication of
pus, and sensitive broad-spectrum antibiotics [18]. Pathak et al.
described 41 cases with subdural empyema from 1977 to 1988;
only four of patients had parafalcine collection [6]. In
falcotentorial empyema, craniotomy is the choice [39]. The pus
is evacuated and the wall is partially excised, laying it completely
open, unless it is extremely thin. With appropriate surgery and
antibiotic therapy, a good outcome can be expected (Fig. 5). In
infratentorial empyema, early surgery can salvage most patients
and obviate the need for permanent CSF diversion procedures
[39–41]. Surgery (evacuation of empyema and mastoidectomy
or clearing up paranasal sinuses), antibiotics, and management of
hydrocephalus are the mainstays of treatment. Although most
patients have hydrocephalus at presentation, a small number
need permanent CSF diversion [24]. External ventricular drain
(EVD) can be used both as a temporizing measure to control
hydrocephalus and measure ICP as long as it is required.
Reoperation may be needed if there is significant residual
empyema, recurrent collections, intraparenchymal abscess,
and associated posterior fossa SDE. All patients who have
otitis media or paranasal sinusitis require a specialist ENT
surgeon’s attention during management.
Fig. 4 A-2-month-old female child, presented with fever, purulent ear
discharge, and signs of raised intracranial pressure. CT scan revealed
posterior fossa subdural empyema. Pus did not grow any organism. a
Axial contrast CT image. b Coronal contrast image
Patients who underwent craniotomy had better outcomes
and lesser incidence of repeat surgery for significant residual/
new supratentorial SDEs [38]. Smith and Hendrick [38] in
their series of 22 pediatric cases emphasized the importance
of craniotomy in achieving better outcomes similar to Yilmaz
et al. [42] in their series of 28 cases. In most patients, general
anesthesia is preferred, although mild sedation and local an-
esthesia can be considered in medically ill patients.
Single or multiple burr holes are usually advocated when
patient is in septic shock, in emergency decompression or
situations, or situations where the patient is considered very
frail [24, 32, 38, 43]. The disadvantage of burr holes is that in
multi-loculated subdural collections, it can lead to secondary
injury of the cortex and therefore might exacerbate infections.
There is a higher recurrence rate reported. Burr hole evacua-
tion had a mortality of 48% in contrast to 8% in those treated
by a craniotomy. Properly placed burr holes, located according
to etiology, clinical picture, and CT scan, is the
preferreprocedure in unconscious patients since pus remains
as an extended thin film in the acute stage.
Neuroendoscope, rigid or flexible with working and/or irriga-
tion channels with frame-based or frameless neuronavigation

Fig. 5 A-10-day-old female child, 32-week gestation preterm, fever, and
sepsis. Blood culture grew Acinetobacter. She presented with increasing
head circumference. CT plain and contrast showed multiple subdural
empyema in the left frontal region and bilateral posterior fossa subdural
empyema. It resolved with antibiotic treatment. a Axial contrast CT im-
age. b Sagittal contrast CT image
system can be used as an adjunct for better visualization and
access in relatively difficult areas and facilitating drainage of
purulent material [29]. There are limitations in using stereotaxic
frame in small children due to variability in their head size and
technical difficulty in pin fixation.
Complications
Subdural empyema may progress to recurrent meningitis, cor-
tical venous thrombosis, or brain abscess. It can rapidly spread
to involve an entire cerebral hemisphere. If left untreated,
Childs Nerv Syst
subdural empyema can be fatal. It can lead to coma and per-
manent neurological deterioration.
Outcome and prognostication
The prognosis is good if diagnosis is early and treatment is
promptly instituted. The survival rate is more than 90% if
timely surgical intervention is carried out. The morbidity is
less than 10% if intervention is carried out within 72 h [5–8,
11, 12, 33, 38]. The extent of subdural pus accumulation has a
statistically significant bearing on the chances of survival. The
morbidity and mortality is significantly less in supratentorial
subdural empyema than in infratentorial location. The integ-
rity of the arachnoid membrane as well as the protective effect
of the altered blood flow in the cortex underlying the empy-
ema could be responsible. Neurological deficits and cerebral
herniation on CT scan are indicators of poor prognosis in
patients with SDE [44]. Young patients, stable neurological
status, viz., patient alert and awake, paranasal sinus as site of
infection, aerobic streptococci isolated, drainage of pus
through a craniotomy. The prognosis is bad if patient is elderly
or younger than 10 years, comatose on presentation, no local-
izing features, delay in referral and administration of antibiotic
therapy, pus is diffusely spread, and cultures are sterile.
Conclusion
Subdural empyema is a neurosurgical emergency and a poten-
tially life-threatening entity. The clinical symptomatology is
subtle and a high degree of clinical awareness is essential.
Early diagnosis, referral, and intravenous administration of
broad-spectrum antibiotics is paramount. Conservative man-
agement with antibiotics and follow-up imaging is recom-
mended if there are no focal deficits, no change in mental
status, or if the patient is responding well to antibiotics.
Craniotomy is preferred to ensure near complete evacuation
of the subdural empyema. Burr holes can be done if the patient
is frail or in septic shock. Early diagnosis and treatment is a
prerequisite for a gratifying outcome.
Compliance with ethical standards
Conflict of interest On behalf of all authors, the corresponding author
states that there is no conflict of interest.
References
1. Khan M, Griebel R (1984) Subdural empyema: a retrospective
study of 15 patients. Can J Surg 27:283–288
2. Kubik CS, Adams RD (1943) Subdural empyema. Brain 66:18–42
Childs Nerv Syst
3. Liu ZH, Chen NY, Tu PH, Lee ST, Wu CT (2010) The treatment
and outcome of postmeningitic subdural empyema in infants. J
Neurosurg Pediatr 6(1):38–42
4. De Bonis P, Anile C, Pompucci A, Labonia M, Lucantoni C,
Mangiola A (2009) Cranial and spinal subdural empyema. Br J
Neurosurg 23(3):335–340
5. Agrawal A, Timothy J, Pandit L, Shetty L, Shetty JP (2007) A
review of subdural empyema and its management. Infect Dis Clin
Pract (Baltim Md) 15(3):149–153
6. Pathak A, Sharma BS, Mathuriya SN, Khosla VK, Khandelwal N,
Kak VK (1990) Controversies in the management of subdural em-
pyema. A study of 41 cases with review of literature. Acta
Neurochir 102:25–32
7. Venkatesh MS, Pandey P, Devi BI, Khanapure K, Satish S,
Sampath S, Chandramouli BA, Sastry KV (2006) Pediatric
infratentorial subdural empyema: analysis of 14 cases. J
Neurosurg 105:370–377
8. Patel NA, Garber D, Hu S, Kamat A (2016) Systematic review and
case report: intracranial complications of pediatric sinusitis. Int J
Pediatr Otorhinolaryngol 86:200–212
9. Benevides GN, Salgado GA Jr, Ferreira CR, Felipe-Silva A, Gilio
AE (2015) Bacterial sinusitis and its frightening complications:
subdural empyema and Lemierre syndrome. Autops Case Rep 5:
19–26
10. Germiller JA, Sparano AM (2006) Intracranial complications of
sinusitis in children and adolescents and their outcomes. Arch
Otolaryngol Head Neck Surg 132:969–976
11. Cowie R, Williams B (1983) Late seizures and morbidity after
subdural empyema. J Neurosurg 58:569–573
12. Niklewski F, Petridis AK, Al Hourani J, Blaeser K, Ntoulias G,
Bitter A, Rosenbaum T, Scholz M (2013) Pediatric parafalcine em-
pyemas. J Surg Case Rep Aug 29:2013(8)
13. Garfield J (1969) Management of supratentorial intracranial ab-
scess: a review of 200 cases. Br Med J 2:7–11
14. Hitchcock E, Andreadis A (1964) Subdural empyema—a review of
29 cases. J Neurol Neurosurg Psychiatry 27:422–434
15. Williams B (1982) Subdural empyema. In: Krayenbuhl H et al (eds)
Advances and technical standards in neurosurgery, vol Vol 9.
Springer, Wien New York, pp 133–170
16. Turel MK, Moorthy RK, Rajshekhar V (2012) Multidrug-resistant
tuberculous subdural empyema with secondary methicillin-resistant
Staphylococcus aureus infection: an unusual presentation of cranial
tuberculosis in an infant. Neurol India 60(2):231–234
17. Vijayakumar B, Sarin K, Mohan G (2012) Tuberculous brain ab-
scess and subdural empyema in an immunocompetent child: signif-
icance of AFB staining in aspirated pus. Ann Indian Acad Neurol
15(2):130–133
18. Banerjee AD, Pandey P, Ambekar S, Chandramouli BA (2010)
Pediatric intracranial subdural empyema caused by
Mycobacterium tuberculosis—a case report and review of litera-
ture. Childs Nerv Syst 26(8):1117–1120
19. Dwarakanath S, Suri A, Mahapatra AK (2004) Spontaneous sub-
dural empyema in falciparum malaria: a case study. J Vector Borne
Dis 41(3–4):80–82
20. Williams V, Lakshmikantha KM, Nallasamy K, Sudeep KC,
Baranwal AK, Jayashree M (2018) Subdural empyema due to
Salmonella paratyphi B in an infant: a case report and review of
literature. Childs Nerv Syst. https://doi.org/10.1007/s00381-018-
3825-7
21. Surinder K, Bineeta K, Megha M (2007) Latex particle agglutina-
tion test as an adjunct to the diagnosis of bacterial meningitis.
Indian J Med Microbiol 25(4):395–397
22. Kanu OO, Nnoli C, Olowoyeye O, Ojo O, Esezobor C, Adeyomoye
A, Bankole O, Asoegwu C, Temiye E (2014) Infantile subdural
empyema: the role of brain sonography and percutaneous subdural
tapping in a resource-challenged region. J Neurosci Rural Pract
5(4):355–359
23. Gupta S, Vachhrajani S, Kulkarni AV, Taylor MD, Dirks P, Drake
JM, Rutka JT (2011) Neurosurgical management of extraaxial cen-
tral nervous system infections in children. J Neurosurg Pediatr 7(5):
441–451
24. Hendaus MA (2013) Subdural empyema in children. Glob J Health
Sci 14; 5(6):54–59
25. Waseem M, Khan S, Bomann S (2008) Subdural empyema com-
plicating sinusitis. J Emerg Med 35(3):277–281
26. Garlick R (1986) Subdural empyema. Br Med J 293:336–337
27. Prober CG, Bachrach LK, Humphreys RP, Hendrick BE, Mehten
KG, Rapley WA (1985) An unusual case of intracranial suppura-
tion. Pediatr Infect Dis J 4:101–103
28. Hodges J, Anslaw P, Gillett G (1986) Subdural empyema—con-
tinuing diagnostic problem in the CT scan era. Q J Med (NS)
59(228):387–393
29. Bruner DI, Littlejohn L, Pritchard A (2012) Subdural empyema
presenting with seizure, confusion, and focal weakness. West J
Emerg Med 13(6):509–511
30. Aldinger FA, Shiban E, Gempt J, Meyer B, Kreutzer J, Krieg SM
(2013) Hollow screws: a diagnostic tool for intracranial empyema.
Acta Neurochir 155(2):373–377
31. Wu TJ, Chiu NC, Huang FY (2008) Subdural empyema in chil-
dren—20-year experience in a medical center. J Microbiol Immunol
Infect 41(1):62–67
32. Lefebvre L, Metellus P, Dufour H, Bruder N (2009) Linezolid for
treatment of subdural empyema due to Streptococcus: case reports.
Surg Neurol 71(1):89–91
33. Madhugiri VS, Sastri BV, Bhagavatula ID, Sampath S,
Chandramouli BA, Pandey P (2011) Posterior fossa subdural em-
pyema in children—management and outcome. Childs Nerv Syst
27:137–144
34. Mauser HW, Ravijst RAP, Elderson A, van Gijn J, Tulleken CAF
(1985) Nonsurgical treatment of subdural empyema. Case report. J
Neurosurg 63:128–130
35. Jacobson PL, Farmer TW (1981) Subdurai empyema complicating
meningitis in infants: improved prognosis. Neurology 31:190–193
36. Mahapatra AK, Bhatia R (1987) Salmonella intracerebral and sub-
dural abscess—a report of two cases. Postgrad Med J 63:373–375
37. Smith HP, Hendrick EB (1983) Subdural empyema and epidural
abscess in children. J Neurosurg 58:392–397
38. Nathoo N, Nadvi SS, Gouws E, van Dellen JR (2001) Craniotomy
improves outcomes for cranial empyema in computed tomography
era experience with 699 patients. Neurosurgery 49(4):872–878
39. Salunke PS, Malik V, Kovai P, Mukherjee KK (2011) Falcotentorial
subdural empyema: analysis of 10 cases. Acta Neurochir 153(1):
164–169
40. Neromyliotis E, Giakoumettis D, Drosos E, Nikas I, Blionas A,
Sfakianos G, Themistocleous MS (2018) Pediatric infratentorial
subdural empyema: a case report. Surg Neurol Int 24(9):104
41. Mohindra S, Kursa GK, Reddy R (2015) Bilateral symmetrical
infratentorial subdural empyema: delay proves detrimental. J
Pediatr Neurosci 10(3):285–286
42. Yilmaz N, Kiymaz N, Yilmaz C, Bay A, Yuca SA, Mumcu C,
Caksen H (2006) Surgical treatment outcome of subdural empy-
ema: a clinical study. Pediatr Neurosurg 42(5):293–298
43. Bok AP, Peter JC (1993) Subdural empyema: burr holes or crani-
otomy? A retrospective computerized tomography-era analysis of
treatment in 90 cases. J Neurosurg 78:574–578
44. Legrand M, Roujeau T, Meyer P, Carli P, Orliaguet G, Blanot S
(2009) Paediatric intracranial empyema: differences according to
age. Eur J Pediatr 168(10):1235–1241