Subdural empyema natural history, complications and prognosis
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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]; Anthony Gallo, B.S. [3]
Overview
Subdural empyema, also referred to as subdural abscess, pachymeningitis interna and circumscript meningitis, is a life-threatening infection.[1] It 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]
Natural History
The subdural empyema may develop from two different conditions, according to the age of the individual. In children, subdural empyema is most frequently a complication of meningitis while in adults it's more frequently a complication of sinusitis otitis or mastoiditis. It may also occur as a complication of head trauma or of a neurosurgical procedure. Depending on the source of infection the etiologic organism will then be different. Subdural empyema is considered a neurological emergency, because if untreated, it frequently evolves into coma and death. With early diagnosis and appropriate treatment, it usually resolves without further complications. At presentation, patients usually complain of fever, headache, nausea/ vomiting, neck stiffness and seizures. With clinical suspicion of subdural empyema, broad-spectrum antibiotics should be initiated, until a more specific diagnosis of the etiological agent is known, at which time, therapy should be directed to that agent.
Complications
Subdural empyema is a condition which, if not treated appropriately and in a timely manner, can progress into serious complications, that may lead invariably to a fatal outcome. An untreated subdural empyema may evolve into: [1]
- Status epilepticus
- Neurological deficits
- Spreading cortico-venous sinus thrombosis
- Cerebritis
- Cerebral edema
- Cerebral infarction
- Hydrocephalus
- Osteomyelitis
- Mortality
There may also be complications from the treatment of the empyema, such as:
- Damage to the bridging veins during the craniotomy procedure to evacuate the empyema.
Prognosis
The outcome is dependent on:[1]
- Preoperative level of consciousness
- Start time of the treatment
- Treatment aggressiveness
- Disease progression
Patient education is imperative as failure to follow antibiotic therapy will adversely affect the outcome of the treatment. Identified prognostic factors associated with subdural empyema include:[1]
Unfavorable Prognostic Factors
- Presenting with encephalopathy or coma
- Younger than 10 years or elderly
- Late start of antibiotics
- Sterile cultures
Favorable Prognostic Factors
- Craniotomy instead of burr holes as surgical procedure
- Early treatment
- Young age (optimal between 10-20 years)
- Patient presents awake, alert and oriented
- Source of infection: paranasal sinuses
- Aerobic streptococci isolated in culture
- Aerobic streptococci as single pathogen
References
- ↑ 1.0 1.1 1.2 1.3 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.
- ↑ Greenlee JE (2003). "Subdural Empyema". Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.