Overview
Subdural empyema (SDE) is a severe, often life-threatening infection within the subdural space, typically requiring urgent neurosurgical intervention for drainage. Escherichia coli is an uncommon but notable pathogen in pediatric cases, often associated with pre-existing subdural hematomas 1.Diagnosis
Clinical presentation includes fever, altered mental status, focal neurological deficits, and signs of increased intracranial pressure 1.
Imaging studies (CT or MRI) are crucial, showing characteristic collections of fluid with high density or signal intensity indicative of empyema 1.
Lumbar puncture may be contraindicated due to increased intracranial pressure but can be considered if there is no suspicion of mass effect 1.
Cultures from surgical drainage or cerebrospinal fluid (if obtained) are essential for identifying the causative organism 1.Management
First-line treatment: Urgent surgical drainage, either through burr holes or craniotomy, depending on the extent and severity of the empyema 1.
Adjunctive antimicrobial therapy: Broad-spectrum antibiotics initiated preoperatively, tailored based on culture and sensitivity results 1.
Close monitoring: Frequent neurological assessments and imaging to evaluate response to treatment and detect complications 1.Special Populations
Pediatrics: Infants and young children may present with fulminant progression despite aggressive surgical interventions; wider craniotomy thresholds may be warranted 1.
Comorbidities: Cases associated with chronic subdural hematomas may exhibit less aggressive behavior but still require vigilant management 1.Key Recommendations
Perform urgent surgical drainage (burr holes or craniotomy) for suspected subdural empyema to prevent neurological deterioration 1 (Evidence: Strong).
Initiate broad-spectrum antibiotics preoperatively and tailor therapy based on culture results 1 (Evidence: Moderate).
Consider lowering the threshold for wide craniotomy in pediatric cases, especially when infection persists despite initial burr hole drainage 1 (Evidence: Weak).References
1 Chen JA, Mathios D, Hidalgo J, Cohen AR. Treatment-refractory Escherichia coli subdural empyema caused by infection of a chronic subdural hematoma in an infant. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2019. link
2 Fender LJ, Lenthall RK, Jaspan T. De novo development of presumed cavernomas following resolution of E. Coli subdural empyemas. Neuroradiology 2000. link