Journal of Neurology, Neurosurgery, and Psychiatry 1986;49:635-639

Management of subdural intracranial empyemasshould not always require surgeryD LEYS, A DESTEE, H PETIT, P WAROT

From the Department of Neurology, University of Lille, Lille, France

SUMMARY Seven patients with subdural empyema were initially treated by antibiotics withoutsurgery. Six have recovered without sequelae. One required delayed surgery and has recovered withepilepsy. The authors emphasise the use of CT for the diagnosis and follow-up of subdural empy-ema, the principles and modalities of non-surgical treatment, and the good results, especially for latemorbidity.

From the medical literature, it is evident that, evenwhen antibiotics became available, most authors haveagreed there is need for surgery in all intracranialsubdural empyemas.' However, this treatment hasnot prevented serious mortality'4 and sequelaes.' sSince the use ofCT for the diagnosis of various centralnervous system suppurations,6 7 some authors havetreated brain abscesses, 6 8 -10 extradural/intracranialabscesses" and even spinal epidural abscesses7 with-out surgery. We report here the results obtained with7 patients with subdural empyema treated withoutsurgery.

Case reports

The first three patients have been the subject of a previousreport in a review about clinical and radiological findings insubdural empyemas. The second patient's history is reportedin detail, and the six others are summarised in the table. Eachpatient's CT scan, before and after treatment, is shown in thefigs 1-5.

Patient 2This 19-year-old woman had a 1 week history of fever andbifrontal headache and received each day amoxicilline (1 gorally) for 4 days. She was admitted to the neurologicaldepartment on 13 April 1982 with fever (38°5), headache andvomiting. She was lethargic, with a left hemiplegia and apalsy of both external recti. Her neck was stiff. Generalizedseizures occurred. CSF contained 900 white cells/mm3(100% polymorphonuclear), protein 0-6mg/l and glucose0-6 g/l. ESR was 120 mm/h and WBC count was 15000(80% polymorphonuclear). CT (fig 2a) revealed aninterhemispheric area of low density with an enhanced thin

Address for reprint requests: Pr P Warot, MD, Department ofNeurology A, Hospital B, 2 avenue Oscar Lambret, F59037 LilleCedex, France.

Received 12 April 1985 and in revised form 18 September 1985.Accepted 21 September 1985.

margin after contrast and compression of cerebral andventricular structures. No causative organism was isolatedfrom CSF or blood cultures. Skull radiographs showedopacification of the right maxillary and frontal sinuses.The patient was treated by ampicillin (12gIV), sisomicine(150 mg IM) and trimethoprim-sulfamethoxazole (320mg-1600mg IV) for 6 weeks, then by oral amoxicillin 6gdaily for 4 months. Clonazepam (3 mg IV) was added duringthe first 48 hours and mannitol during the first 5 days. Whenthe treatment was stopped, she had no neurological deficitand CT scan (fig 2b) showed no abnormalities. Thirtymonths later, she had had no seizure, and did not receiveanticonvulsant medication.

Discussion

The use of CTfor diagnosis andfollow-upAs in brain abscesses,6 a non-surgical treatment ofsubdural empyemas is possible only ifCT can be per-formed. It reveals small empyemas which could not bediagnosed otherwise, as in the second case reported byRosazza:'3 this was a patient with purulent meningitisand without any focal deficit, in whom CT showed asmall subdural empyema. CT also allows easy andatraumatic follow-up.2 14

The classical treatment of subdural empyemasFor most authors, surgery is always required in allsubdural empyemas: they often prefer a largecraniotomy' 3 15 16 to burr holes, so as to providepurulent material and allow an irrigation of the sub-dural space with antibiotics.'6 For these authors, thesurgical treatment must be performed in emergency,but Pimontel-Appel'4 prefers to wait for an im-provement of the neurological state, 24 to 48 hoursafter the onset of antibiotic therapy. In spite of thepossibility of improvement with surgical treatment,the importance of antibiotics cannot be neglected.The first successfully treated cases occurred only

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Table Cases of non-surgically treated subdural empyemas

Authors Sex and Clinical signs CSF ESRmm/h WBC/mm3 CT scanage(yr) Cells P G

Rasazza13 M 14 fever 33 1200 720 17400 IH SDEheadacheleft hemiplegia

Rasazza13 M 11 fever 316 1500 721 ? 17300 IH SDEmeningism

Rousseaux20 M 24 fever 255 ? ? IH SDEmeningismleft hemiplegia

Case 1 M 29 fever 830 800 500 26 11600 IH SDE802284 focal seizures left PA

generalised status SDEwith coma right (fig 1)hemiplegia and aphasia

Case 2 F 19 fever 900 600 600 120 15000 IH SDE820869 generalised seizures (fig 2)

left hemiplegiaVI palsy meningism

Case 3 M 22 fever 50 550 700 85 15100 FR SDE821121 focal seizures (fig 3)

comaright hemiplegia

Case 4 M 40 fever 5 400 800 60 13000 FR SDE830286 generalised seizures (fig 4)

right hemiplegiameningism

Case 5 M 56 fever 50 400 500 100 22000 whole convexity SDE831075 generalized status (fig 5)

with coma meningismright hemiplegia

Case 6 M 15 fever 80 300 500 15 6000 FR SDE840544 meningism (fig 6)

Case 7 F 24 fever 100 1100 740 80 12000 IH SDE841050 focal and generalised TE SDE

seizures with coma (fig 7)meningism aphasia

M, male; F, female; P, proteins (mg/i); G, glucose (mg/i); SDE, subdural empyema; IH, interhemispheric; PA, parietal; FR, frontal; TE, temporal;T R, total recovery; Ampi, ampicillin; TMP-SMX, trimethoprime-sulfamethoxazole; Siso, sisomicine; Amox, amoxicilline; Metro, metronidazole;PRIS, pristinamycine.

after the introduction of penicillin.'7 More recently,ampicillin and especially chloramphenicol have beenpreferred, because of their good diffusion into thecentral nervous system'3 1' and their effectiveness onanaerobic organisms, which are frequently isolatedfrom subdural empyemas.18

rrWhy have we tried a non-surgical treatment?Surgery has usually been performed as an emergencybecause of two objections to a non-surgical treatment:firstly, antibiotics do not penetrate into loculated in-tracranial suppurations, and secondly, it is necessaryto know the causative organism and its sensibility to

Fig I (Patient 1) (a) On admission: interhemispheric and left parietal subduralempyema. (b) After a 30 day course of antibiotics: disappearance of the most part ofthe empyema, but increase of the posterior part. (c) A year later: no residual empyema.

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Management of subdural intracranial empyemas should not always require surgery

Point of entry Organism Treatment Clinical outcome

Antibiotics Associated medications

sinusitis unknown Ampi Dexamethazone TRChloramphenicol(3 weeks IV5 weeks orally)

sinusitis staphylococcus Ampi IV sinusitis drainage TR6 weeks

sinusitis unknown Ampi IV Tetracosactide TR6 weeks sinusitis

drainagesinusitis streptococcus Ampi IV Mannitol seizures

TMP-SMX 6 weeks ClonazepamSiso IM J craniotomy

(26th day)

sinusitis unknown Ampi Mannitol TRTMP-SMX 6 weeks ClonazepamSiso f

Amox 4 monthssinusitis unknown Ampi Mannitol TR

TMP-SMX 8 weeks ClonazepamSiso JAmox 5 months

sinusitis unknown Ampi Mannitol TRTMP-SMX 4 weeks ClonazepamMetro J sinusitisAmox 3 months drainage

otitis unknown Ampi Mannitol TRTMP-SMX 4 months ClonazepamSiso J surgical treatment

otitissinusitis unknown Ampi } 5 weeks TR

Amox 4 monthspost-traumatic unknown Ampi \4 weeks Mannitol TRsinusitis TMP-SMX > Clonaxepam surgical

PRIS 3 months treatment ofpost-traumatic sinuslesion

antibiotics. To our knowledge, antibiotic has neverbeen found in the pus of subdural empyemas, as it hasin brain abscesses;"9 nevertheless, in our cases 2 to 7,antibiotics were sufficient to improve the patients'state and to normalise the CT scan. In two of Rosa-zza's cases13 and in Rousseaux' case,20 antibioticshad also been able to cure such lesions. Our firstpatient was surgically treated one. month after the

Fig 2 (Patient 2) (a) On adnission: interhemisphericsubdural empyema. (b) During the 6th month: CT scan isnormal.

onset of the antibiotherapy: his neurological condi-tion had improved, but surgery was decided becausethe size of the most posterior part of the empyema hadgradually increased; this patient was our firstmedically treated patient but now, with Rosazza andRousseaux' experiences,1320 and from our next sixpatients, we think that it would have been possible totreat him without surgery. In Kaufman' 21 and

0rT)_IL ieLN&:Fig 3 (Patient 3) (a) On admission: frontal subduralempyema. (b) Eight months later: no residual empyema.

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Leys, Destee, Petit, Warot

a.... .....

Fig 4 (Patient 4) (a) On admission: interhemisphericsubdural empyema. (b) Four months later. no residualempyema.

Holtzman' 22 cases, the neurological condition deteri-orated in spite of antibiotics. We are not sure whetherthe dosage was sufficient, but, in our cases, althoughthe patients often showed a little deterioration duringthe first 24 or 48 hours, we always continued the sametreatment. So, we think that antibiotics are probablyable to penetrate into subdural empyemas. The pushas been free of organisms in our patient 1 and re-ported by Borzone et al.23 This penetration is perhapsmade possible by an unusual development of men-ingeal arteries, as in our third case, which broughtlarge quantities of antibiotics in the margin of theempyema. 24 25

It is not always necessary to know the causativeorganism from the empyema itself. In our seven cases,the causative organism was found only in the firstpatient, from blood cultures. Surgery is not indicatedfor identification of the organism as in brain abs-cesses; this is possible in less than 50% of the operatedcases, and in 30% of the non-surgically treated ones,from blood or CSF cultures, or from the point ofentry; moreover, the organism is, in most cases, sensi-tive to large spectrum antibiotics used intravenouslywith high doses.

Modalities of the medical treatmentWe have used intravenous antibiotic therapy for 4 to

Fig 6 (Patient 6) (a) On admission: right frontalsubdural empyema. (b) Four months later: no residualempyema.

6 weeks and oral antibiotics until the CT scan wasnormal in all cases except the first in which the patienthimself stopped the treatment in the sixth week. Wethink it is possible to stop earlier, as in Rosazza'cases,'3 but care is required to ensure sterilisation ofthese lesions. Clonazepam was used when generalisedseizures occurred. Corticosteroids have been avoidedduring the acute phase as they prevent antibioticsfrom penetrating into the abscesses.8 To prevent oe-dema, 10% hypertonic mannitol was used during thefirst few days. Of course, surgical treatment mighthave been necessary for patients who were rapidlydeteriorating neurologically with medical treatment.However, in our second and seventh cases, a littledeterioration did not lead to surgery. In four cases,antibiotics alone were sufficient to treat the initialinfection of paranasal sinuses; in one case, delayedsurgery prevented relapse and in two cases, earlysurgery was necessary to treat the paranasal sinusitis.

Results

With classical treatment, associating emergencysurgery and antibiotics, the mortality washigh' 23 26 - 28 and sequelae (focal deficits or epilepticseizures) were frequent.' 5 In our cases, only one pa-tient had sequelae, (generalised seizures) and he had

_..1:.

....

Fig 5 (Patient S) (a) On admission: subdural empyemaof the whole convexity. (b) One year later: CT scan isnormal.

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Management of subdural intracranial empyemas should not always require surgery

been operated upon. After 6 to 30 months, the othersix have no focal deficit or seizure. The three otherpatients previously reported13 20 in the literature, alsohave had no sequelae.

For these 10 cases, summarised in the table, themorbidity and mortality obtained by medical treat-ment alone seem better than those by surgical treat-ment,28 as also shown in brain abscesses.'0 Manystudies have shown that the most important prognos-tic factor in intracranial infection is the level of con-sciousness when the treatment is commenced. Threepatients (cases 2, 4, 6) were not in coma and they maytherefore have been expected to have a better prog-nosis, no matter how they were treated. Nevertheless,the four others were in coma, and three had totalrecovery, and one little sequelae. In the literature, withsurgery, the mortality and morbidity seem higher.28A long period of intravenous treatment may be a

financial disadvantage as compared with perhaps amore rapid response to surgical drainage, leading toearlier discharge and cheaper overall treatment; nev-ertheless, shorter treatments are possible, as in ourfirst patient, and it would be possible to dischargethese patients earlier in the future, when our experi-ence will be greater. Moreover, less sequelae is also afinancial advantage.

The authors thank Mr Francois Leung for the re-vision of the English manuscript.

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