Внутрішньочерепний епідуральний абсцес і субдуральна емпієма

Cranial epidural abscess and subdural empyema are usually complications of sinusitis (especially frontal, ethmoidal, or sphenoidal) or otitis media, but they can follow other ear infections, cranial trauma or surgery, or, rarely, bacteremia. Pathogens are similar to those that cause brain abscess (eg, Staphylococcus aureus, Bacteroides fragilis).

In children < 5 years old, the usual cause is bacterial meningitis; because childhood meningitis is now uncommon, childhood subdural empyema is uncommon.

Fever, headache, lethargy, focal neurologic deficits (often indicating subdural empyema when rapidly developing deficits suggest widespread involvement of one cerebral hemisphere), and seizures usually evolve over several days.

Patients with intracranial epidural abscess may also develop a subperiosteal abscess and osteomyelitis of the frontal bone (Pott puffy tumor) (1), and patients with subdural empyema often develop meningeal signs. In epidural abscess and subdural empyema, vomiting is common. Patients may develop papilledema.

Without treatment, coma and death occur rapidly, particularly in subdural empyema.

• Contrast-enhanced MRI

Diagnosis of epidural abscess or subdural empyema is by contrast-enhanced MRI or, if MRI is not available, by contrast-enhanced CT. Blood and surgical specimens are cultured aerobically and anaerobically.

Lumbar puncture provides little useful information and may precipitate transtentorial brain herniation. If intracranial epidural abscess or subdural empyema is suspected (eg, based on symptom duration of several days, focal deficits, or risk factors) in patients with meningeal signs, lumbar puncture is contraindicated until neuroimaging excludes a mass lesion.

In infants, a subdural tap may be diagnostic and may relieve pressure.

• Surgical drainage

• Antibiotics

Emergency surgical drainage of the epidural abscess or subdural empyema and any underlying fluid in the sinuses should be done.

Pending culture results, antibiotic coverage is the same as antibiotics used to treat brain abscess (eg, cefotaxime, ceftriaxone, metronidazole, vancomycin) except in young children, who may require other antibiotics for any accompanying meningitis (see tables Initial Antibiotics for Acute Bacterial Meningitis and Common IV Antibiotic Dosages for Acute Bacterial Meningitis).

Antiseizure medications may be required to control seizures but are not usually used prophylactically. Medications such as mannitol or dexamethasone may be needed if there is evidence of increased intracranial pressure. Hemicraniectomy may be required if intracranial pressure cannot be otherwise controlled.