Subdural empyema

Background

• Usually complications of sinusitis (especially frontal, ethmoidal, or sphenoidal) or otitis media
  • Other causes include other ear infections, cranial trauma or surgery, or rarely bacteremia
  • In children <5yo, cause is typically bacterial meningitis
• Typically due to epidural abscess extending into subdural space to cause subdural empyema

Clinical Features

• Fever
• Headache
• Lethargy
• Focal neuro deficits, particularly with rapidly developing neuro deficits suggesting involvement of entire hemisphere
• Seizures
• Complications
  • Meningitis
  • Cortical venous thrombosis
  • Brain abscess

Differential Diagnosis

• CVA
• Meningitis, encephalitis
• Malignancy

Intracranial Mass

• Intracranial hemorrhage
  • Intra-axial
    • Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
    • Traumatic intracerebral hemorrhage
  • Extra-axial
    • Epidural hemorrhage
    • Subdural hemorrhage
    • Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)
• Brain tumor
• Brain abscess
• Subdural empyema
• Epidural abscess (intracranial)

Evaluation

• Assess for alternative causes of symptoms (e.g. labs to rule out metabolic process, glucose, infectious workup)
• MRI brain with contrast
• Blood cultures
• Definitive diagnosis by culture of surgical specimens
• LP NOT helpful and may precipitate herniation
• In infants, a subdural tap may be diagnostic and may relieve pressure

Management

• Address airway protection
• Antibiotics similar to those used for brain abscess: e.g. cefotaxime, ceftriaxone, metronidazole, vancomycin
  • In children, cover also for bacterial meningitis
• Emergent neurosurgery consult for drainage

Disposition

• Admit