Abstract
Subdural empyema (SDE) is an infection between the dura and arachnoid mater, presenting with fever, headache, altered sensorium, neurological deficits, and seizures. Early diagnosis and treatment are crucial. We present a 49‑year‑old woman with SDE who underwent emergent craniotomy; cultures grew Streptococcus intermedius. Postoperatively she improved with complete evacuation and resolution of midline shift. A PubMed literature review (1,104 cases) identified common pathogens, demographics, imaging features, treatments, and outcomes. Contrast‑enhanced MRI is key for diagnosis; urgent craniotomy with evacuation and broad‑spectrum antibiotics guided by cultures are recommended.
Introduction
Subdural empyema (SDE) is a life‑threatening collection of pus between the dura and arachnoid mater, accounting for ~20% of intracranial infections. It predominantly affects males aged 10–30. Etiologies include sinusitis, trauma, cranial surgery, and hematogenous spread. Common pathogens are anaerobic and microaerophilic streptococci, Staphylococcus aureus, and Haemophilus influenzae. Rapid invasion leads to increased intracranial pressure, mass effect, and neurologic deterioration. Prompt imaging (contrast MRI), emergent neurosurgical evacuation, and targeted antibiotics are essential to reduce morbidity and mortality.
Case Presentation
Patient: 49‑year‑old woman with type II diabetes and right great toe osteomyelitis (recent amputation).
Presentation: Four‑day headache, confusion, obtundation, left hemiplegia, ptosis. Exam: eyes deviated right/down, facial grimace, left UE withdrawal to pain only.
Figure 1: Clinical Course Timeline
Noncontrast CT & MRI: right hemispheric thin isointense collection; contrast MRI: thick‑walled, peripherally enhancing SDE over right frontotemporal region (Figure 2); FLAIR: temporal lobe hemorrhagic infarct with peripheral enhancement (Figure 3).
Figure 2
Contrast‑enhanced MRI showing thick peripheral enhancement.
Figure 3
FLAIR MRI showing hemorrhagic infarct with enhancement.
An urgent right frontotemporal craniotomy was performed: four burr holes, bone flap removal, dural opening with frank pus egress. Aerobic, anaerobic, fungal, and AFB cultures obtained. Subdural phlegmon and cortical adhesions evacuated; necrotic temporal gyrus resected; two liters saline irrigation; hemostasis with Surgicel; dural closure with Nurolon; bone flap fixed with titanium plates; layered scalp closure.
Figure 4
Intraoperative exposure: pressurized pus draining upon dural reflection.
Discussion
This case underscores Streptococcus anginosus group as a common SDE pathogen and the need for high suspicion in diabetics with head infections. Our PubMed review (12 studies, 1,104 cases) found:
- Mortality: 10.4% overall (168 pediatric cases: 7.1%)
- Demographics: mean age 21 years; 65.2% male (pediatric: mean 10.7 years; 77.3% male)
- Pathogens: S. anginosus (17.5%), β‑hemolytic streptococci (6.9%), anaerobes (6.8%), S. aureus (5.2%), α‑hemolytic streptococci (5.1%), coagulase‑negative staphylococci (4.1%), E. coli (3.3%), Proteus (3.2%), H. influenzae (2.8%), Pseudomonas (2.1%), K. pneumoniae (1.6%), sterile (22.1%), polymicrobial (16.4%).
Figure 5
Bar graph showing prevalence of pathogens in SDE cases.
Rapid imaging (contrast MRI), emergent craniotomy with complete evacuation, and culture‑guided antibiotics (IV ≥2 weeks, oral 4–6 weeks) are critical. Seizure prophylaxis and multidisciplinary management, including dental and rehab services, improve outcomes. Craniotomy is preferred over burr holes due to lower reoperation rates.
Conclusions
Early recognition of SDE via thorough exam and contrast MRI, prompt neurosurgical evacuation, and broad‑spectrum antibiotics tailored by cultures are pivotal. Multidisciplinary care and rehabilitation underpin optimal recovery. Our patient’s excellent nine‑month outcome highlights the benefit of rapid, comprehensive intervention.
Additional Information
Author Contributions
- Data acquisition/analysis: Arbuckle, Abo Kasem, Hwang
- Manuscript drafting: Arbuckle, Abo Kasem, Shaik
- Concept/design: Abo Kasem, Shaik, Downes, Passias, Agarwal, Jea, Janjua
- Critical review: Downes, Hwang, Passias, Agarwal, Jea, Janjua
- Supervision: Janjua
Disclosures
Human subjects: Consent obtained or waived. Conflicts of interest: None declared. No external funding.
