Subdural empyema

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Subdural empyema

Etiology, pathophysiology, clinical presentation, diagnostic approach, and treatment of a bacterial brain abscess, a cranial epidural abscess, and a subdural empyema

PathophysiologyClinical PresentationDiagnosisTreatment
Bacterial brain abscessMCC: streptococci and anaerobes
Posttrauma/surgery: Staphylococcus aureus , Enterobacteriaceae, Pseudomonas aeruginosa
Direct spread from contiguous sites (e.g., sinusitis, mastoiditis, otitis media)
Hematogenous spread from remote site of infection
After cranial trauma/surgery
Fever, headache, focal neurologic deficit, seizuresCT with contrast: hypodense lesion with typically thin ring of contrast enhancement around edge
MRI brain with contrast: ring-enhancing lesion
Antimicrobial therapy and, if amenable, aspiration, drainage, or excision
Cranial epidural abscessSimilar to brain abscessFrontal sinus, middle ear, mastoid, orbit infection reaches epidural space through retrograde spread into emissary veins, direct spread of bone infection, or through craniotomyHemicranial headache with feverMRI: crescent-shaped purulent fluid collection seen more prominently on T1 sequenceImmediate neurosurgical drainage, empiric antimicrobial therapy with third- or fourth-generation cephalosporin, metronidazole, and vancomycin for 4-6 weeks after drainage followed by 2-3 months of oral antibiotic
Subdural empyemaAerobic, microaerophilic, and anaerobic streptococci; staphylococci from neurosurgical procedureCollection of pus between dura and arachnoid, most common predisposing condition is paranasal sinusitis
Less common: mastoiditis, neurosurgical procedure
Signs of infection, increased ICP from expanding lesion, stroke, headache, altered mental status, focal deficitMRI with gadolinium: T1 and FLAIR sequencesEvacuation by drainage or craniotomy, empiric therapy with third- or fourth-generation cephalosporin, metronidazole, vancomycin for 2-3 weeks intravenously then oral antibiotic for 6 weeks


MCC , Most common cause; CT , computed tomography; MRI , magnetic resonance imaging; ICP , intracranial pressure; FLAIR , fluid attenuation inversion recovery.


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