Subdural empyema

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Subdural empyema ~~(SDE)~~ isis uncommon but nonetheless can account for a significant number of intracranial infections.

Epidemiology

Subdural empyemas account for approximately 20-33% of all intracranial infections.

Clinical presentation

Clinical presentation depends to some degree on the aetiology. When empyemas result from sinusitis or mastoiditis they are often associated with seizures, focal neurological deficits and rapid deterioration of consciousness, progressing from obtundation to coma ¹. Empyemas that occur secondary to prior trauma or surgery are usually more clinically indolent.

Pathology

In the most common scenario, patients develop subdural empyemas as a result of frontal sinusitis. There are two putative mechanisms of spread ³:

direct extension
indirect: secondary to thrombophlebitis

Direct spread, resulting from erosion of the posterior wall of the frontal sinus (the corollary of Pott puffy tumour) is relatively uncommon. Thrombophlebitis of communicating veins is thought to be the most common cause of spread ³.

Aetiology

frontal sinusitis: vast majority
mastoiditis/otitis media
surgical intervention
meningitis
trauma
seeding of existing subdural haematoma

~~Complications~~

~~Complications are relatively common and may be the cause of presentation. They include:~~

~~cortical vein thrombosis~~ ~~with or without~~ ~~venous infarction~~

~~cerebritis~~ or ~~cerebral abscess~~ ~~formation~~

Radiographic features

CT is usually the first investigation performed, and often is the only one required, as patients usually expediently proceed to the surgical theatre for evacuation.

CT

Subdural empyemas typically resemble subdural haematomas in their shape and the relationship to sutures and dural reflections. They are typically crescentic in shape (compared to epidural empyemas which are typically lentiform), although collection pockets may appear biconvex (see case 1). A surrounding membrane that enhances intensely and uniformly following contrast administration is typical.

MRI

Appearance on MRI is similar to that on CT, although contrast enhancement is more readily detected. Furthermore, the content of the collection will typically demonstrate restricted diffusion (see case 1).

MRI is also more sensitive to the complications of subdural empyemas, e.g. cerebritis, cerebral abscess, and venous thrombosis.

Treatment and prognosis

Mortality associated with subdural empyemas now approaches 10%, compared with approximately 15-40% in the pre-CT era ¹.

Successful treatment is predicated on prompt diagnosis, followed by surgical evacuation of the collection and administration of appropriate antibiotics.

Complications

Complications are relatively common and may be the cause of presentation. They include:

cortical vein thrombosis with or without venous infarction
cerebritis or cerebral abscess formation

-<p><strong>Subdural empyema (SDE)</strong> is uncommon but nonetheless can account for a significant number of <a href="/articles/intracranial-infections">intracranial infections</a>.</p><h4>Epidemiology</h4><p>Subdural empyemas account for approximately 20-33% of all intracranial infections.</p><h4>Clinical presentation</h4><p>Clinical presentation depends to some degree on the aetiology. When empyemas result from <a title="Acute sinusitis" href="/articles/acute-sinusitis">sinusitis</a> or <a title="Acute mastoiditis" href="/articles/acute-mastoiditis">mastoiditis</a> they are often associated with seizures, focal neurological deficits and rapid deterioration of consciousness, progressing from obtundation to coma <sup>1</sup>. Empyemas that occur secondary to prior trauma or surgery are usually more clinically.</p><h4>Pathology</h4><p>In the most common scenario, patients develop subdural empyemas as a result of frontal <a href="/articles/acute-sinusitis">sinusitis</a>. There are two putative mechanisms of spread <sup>3</sup>:</p><ol>
+<p><strong>Subdural empyema </strong>is uncommon but nonetheless can account for a significant number of <a href="/articles/intracranial-infections">intracranial infections</a>.</p><h4>Epidemiology</h4><p>Subdural empyemas account for approximately 20-33% of all intracranial infections.</p><h4>Clinical presentation</h4><p>Clinical presentation depends to some degree on the aetiology. When empyemas result from <a href="/articles/acute-sinusitis">sinusitis</a> or <a href="/articles/acute-mastoiditis">mastoiditis</a> they are often associated with seizures, focal neurological deficits and rapid deterioration of consciousness, progressing from obtundation to coma <sup>1</sup>. Empyemas that occur secondary to prior trauma or surgery are usually more clinically indolent.</p><h4>Pathology</h4><p>In the most common scenario, patients develop subdural empyemas as a result of frontal <a href="/articles/acute-sinusitis">sinusitis</a>. There are two putative mechanisms of spread <sup>3</sup>:</p><ol>
-</ol><p>Direct spread, resulting from erosion of the posterior wall of the frontal sinus (the corollary of <a title="Pott puffy tumour" href="/articles/pott-puffy-tumour">Pott </a><a title="Pott puffy tumour" href="/articles/pott-puffy-tumour">puffy</a><a title="Pott puffy tumour" href="/articles/pott-puffy-tumour"> tumour</a>) is relatively uncommon. Thrombophlebitis of communicating veins is thought to be the most common cause of spread <sup>3</sup>.</p><h5>Aetiology</h5><ul>
+</ol><p>Direct spread, resulting from erosion of the posterior wall of the frontal sinus (the corollary of <a href="/articles/pott-puffy-tumour">Pott </a><a href="/articles/pott-puffy-tumour">puffy</a><a href="/articles/pott-puffy-tumour"> tumour</a>) is relatively uncommon. Thrombophlebitis of communicating veins is thought to be the most common cause of spread <sup>3</sup>.</p><h5>Aetiology</h5><ul>
~~-</ul><h5>Complications</h5><p>Complications are relatively common and may be the cause of presentation. They include:</p><ul>~~
+</ul><h4>Radiographic features</h4><p>CT is usually the first investigation performed, and often is the only one required, as patients usually expediently proceed to the surgical theatre for evacuation.</p><h5>CT</h5><p>Subdural empyemas typically resemble <a href="/articles/subdural-haemorrhage">subdural haematomas</a> in their shape and the relationship to sutures and dural reflections. They are typically crescentic in shape (compared to <a href="/articles/epidural-empyema">epidural empyemas</a> which are typically lentiform), although collection pockets may appear biconvex (see case 1). A surrounding membrane that enhances intensely and uniformly following contrast administration is typical.</p><h5>MRI</h5><p>Appearance on MRI is similar to that on CT, although contrast enhancement is more readily detected. Furthermore, the content of the collection will typically demonstrate restricted diffusion (see case 1).</p><p>MRI is also more sensitive to the complications of subdural empyemas, e.g. cerebritis, cerebral abscess, and venous thrombosis.</p><h4>Treatment and prognosis</h4><p>Mortality associated with subdural empyemas now approaches 10%, compared with approximately 15-40% in the pre-CT era <sup>1</sup>.</p><p>Successful treatment is predicated on prompt diagnosis, followed by surgical evacuation of the collection and administration of appropriate antibiotics.</p><h5>Complications</h5><p>Complications are relatively common and may be the cause of presentation. They include:</p><ul>
~~-<a href="/articles/cortical-vein-thrombosis">cortical vein thrombosis</a> with or without <a href="/articles/cerebral-venous-infarction">venous infarction</a>~~
+<a href="/articles/cortical-vein-thrombosis">cortical vein thrombosis</a> with or without <a href="/articles/cerebral-venous-infarction">venous infarction</a>
~~-<a href="/articles/cerebritis">cerebritis</a> or <a href="/articles/brain-abscess-1">cerebral abscess</a> formation</li>~~
-</ul><h4>Radiographic features</h4><p>CT is usually the first investigation performed, and often is the only one required, as patients usually expediently proceed to the surgical theatre for evacuation.</p><h5>CT</h5><p>Subdural empyemas typically resemble <a title="Subdural haematomas" href="/articles/subdural-haemorrhage">subdural haematomas</a> in their shape and the relationship to sutures and dural reflections. They are typically crescentic in shape (compared to <a href="/articles/epidural-empyema">epidural empyemas</a> which are typically lentiform), although collection pockets may appear biconvex (see case 1). A surrounding membrane that enhances intensely and uniformly following contrast administration is typical.</p><h5>MRI</h5><p>Appearance on MRI is similar to that on CT, although contrast enhancement is more readily detected. Furthermore, the content of the collection will typically demonstrate restricted diffusion (see case 1).</p><p>MRI is also more sensitive to the complications of subdural empyemas, e.g. cerebritis, cerebral abscess, and venous thrombosis.</p><h4>Treatment and prognosis</h4><p>Mortality associated with subdural empyemas now approaches 10%, compared with approximately 15-40% in the pre-CT era <sup>1</sup>.</p><p>Successful treatment is predicated on prompt diagnosis, followed by surgical evacuation of the collection and administration of appropriate antibiotics.</p>
+<a href="/articles/cerebritis">cerebritis</a> or <a href="/articles/brain-abscess-1">cerebral abscess</a> formation</li>
+</ul>

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