Subdural Empyema Treatment & Management

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...
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Medical Care

Prehospital care

Maintain an adequate airway and ensure breathing and circulation by supportive care (eg, oxygen). Establish an intravenous line with adequate monitoring while en route to the emergency department.

Emergency department care

Continue supportive treatment (ie, ABCs) directed toward stabilizing the patient. Request necessary imaging studies and laboratory tests. Commence antibiotic therapy as soon as possible with broad coverage for anaerobes, staphylococci, and aerobic streptococci.

The neurosurgical team should be involved; thoracic surgery and otolaryngology teams also should be consulted if necessary.


Antibiotic therapy [2] alone may be adequate for small subdural empyema (ie, < 1.5 cm diameter). Because of the aggressive nature of this disease, however, this option is not widely utilized. [3] This is an option for patients with major contraindications to surgery or significant mortality risks.

Other medical interventions may include medications for seizure treatment or prophylaxis. Treatment for increased intracranial pressure also has been advocated.

Inpatient care

Recurrence of subdural empyema requires immediate surgical evacuation. If a burr hole was the initial surgical procedure, a craniotomy flap should be considered.

Complications such as seizures and subdural effusion may require more aggressive treatment modalities.

Assess and treat residual neurological deficits. Inpatient rehabilitation (either subacute or acute) may be necessary.

Outpatient care

Outpatient follow-up by the treating medical, surgical, and infectious disease teams is required.

A decision needs to be made concerning whether to continue antiseizure prophylaxis. An EEG may be needed to rule out an epileptic focus.

Outpatient rehabilitation for physical therapy, occupational therapy, and speech therapy may be needed.


Surgical Care

Immediate neurosurgical drainage [4] of the subdural empyema should be considered. The primary surgical option is craniotomy, which allows wide exposure, adequate exploration, and better evacuation of the purulent collection than other procedures. Stereotatic burr hole placement with drainage and irrigation is another option but is less desirable because of decreased exposure and possible incomplete evacuation of the purulent material. [5]

Drainage and debridement of the primary source of infection may be necessary. Samples should be collected for Gram staining, culture, and sensitivity tests.

Patients with contraindications to surgery or significant mortality risks may receive antibiotic therapy alone. [11]

Other surgical interventions may be required to debride or evacuate the primary source of infection. Such efforts may require an otolaryngologist for paranasal sinusitis (eg, bilateral antral washout, mastoidectomy for recurrent chronic mastoiditis, grommets for recurrent otitis media) or a thoracic surgeon for a chronic lung abscess.



See the list below:

  • Neurosurgery, otolaryngology, and thoracic surgery consultations

  • Physical medicine and rehabilitation for physical therapy, gait and balance training, occupational therapy, and speech therapy

  • Clinical psychologist for treatment of any residual cognitive deficit

  • Ophthalmology or optometry consult if a visual defect is present, especially in patients with palsies of cranial nerves III, V, or VI, or visual field defects (eg, homonymous hemianopsia)

  • Home care aides and social work for issues after discharge (About 55% of patients have neurological deficits on discharge.)



Maintaining balance and gait training is important; patients should be assessed and treated in conjunction with the rehabilitation department.