Subdural Empyema Clinical Presentation

Updated: Oct 28, 2022
  • Author: Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
  • Print


A patient with subdural empyema could present with any of the following symptoms:

  • Fever - Temperature above 38°C (100.5°F)

  • Headache - Initially focal and later generalized

  • Recent history (< 2 wk) of sinusitis, [1] otitis media, mastoiditis, meningitis, cranial surgery or trauma, sinus surgery, or pulmonary infection

  • Confusion, drowsiness, stupor, or coma

  • Hemiparesis or hemiplegia

  • Seizure - Focal or generalized

  • Nausea or vomiting

  • Blurred vision (amblyopia)

  • Speech difficulty (dysphasia)

  • History of intracerebral abscess (recent or in the past)



A patient with subdural empyema may show some of the following signs:

  • Mental status changes - Confusion, drowsiness, stupor, and coma

  • Meningismus or meningeal signs

  • Hemiparesis or hemisensory deficits

  • Aphasia or dysarthria

  • Seizure

  • Sinus tenderness, swelling, or inflammation

  • Papilledema and other features of increased intracranial pressure, such as nausea/vomiting, mental status changes, and gait disturbance

  • Homonymous hemianopsia

  • Palsies of cranial nerves III, V, or VI, especially if the abscess is near a petrous portion of the temporal bone, causing facial pain and lateral rectus muscle weakness

  • Fixed, dilated pupil on the ipsilateral side due to compression of cranial nerve III



The most common cause is extension from paranasal sinusitis, especially from the frontal and ethmoidal sinuses. It could also arise as a complication of otitis media, mastoiditis, septicemia, subdural hematoma, [7] cranial trauma or surgery, or recent sinus surgery; by spread or extension from an intracerebral abscess; by hematogenous spread from pulmonary sources; or from septic thrombosis of cranial veins. Common causative organisms are anaerobes, aerobic streptococci, staphylococci, Haemophilus influenzae,Streptococcus pneumoniae, and other gram-negative bacilli.

  • Paranasal sinusitis -Staphylococcus aureus, alpha-hemolytic streptococci, anaerobic streptococci, Bacteroides species, Enterobacteriaceae

  • Otitis media, mastoiditis - Alpha-hemolytic streptococci, Pseudomonas aeruginosa, Bacteroides species, S aureus

  • Trauma, postsurgical infection -S aureus,Staphylococcus epidermidis, Enterobacteriaceae

  • Pulmonary spread -S pneumoniae,Klebsiella pneumoniae

  • Meningitis (infant or child) -S pneumoniae,H influenzae,Escherichia coli,Neisseria meningitidis

  • Neonates - Enterobacteriaceae, group B streptococci, Listeria monocytogenes

  • Others include hematogenous spread from skin postsurgery (eg, abdominal surgery). Spread from a focus of tuberculosis infection could also occur. A case of subdural empyema developing after infection with Plasmodium falciparum malaria.



Complications may include:

  • Seizures

  • Cavernous sinus thrombosis from septic thrombosis of adjacent cerebral veins

  • Increased intracranial pressure

  • Hydrocephalus from compressed cerebrum resulting in interference with CSF flow

  • Cerebral edema from compressed cerebrum leading to interference with cerebral blood flow

  • Cerebral infarction

  • Cranial osteomyelitis, primarily in adjacent cranial bones

  • Residual neurological deficits (eg, hemiparesis, aphasia)