Surgical management of interhemispheric subdural empyemas: Review of the literature and report of 12 cases

Abstract

Background: Subdural empyemas (SDEs) are rare intracranial infections mostly secondary to sinusitis. Incidence of SDEs is 5-25%. Interhemispheric SDEs are even rarer, which makes their diagnosis and treatment difficult. Aggressive surgical interventions and wide-spectrum antibiotics are needed for treatment. In this retrospective clinical study, we intended to evaluate the results of surgical management supported by antibiotics in patients with interhemispheric SDE.

Methods: Clinical and radiological features, medical and surgical management and outcomes of 12 patients treated for interhemi-spheric SDE have been evaluated.

Results: 12 patients were treated for interhemispheric SDE between 2005 and 2019. Ten (84%) were male, two (16%) were female. Mean age was 19 (7-38). Most common complaint was headache (100%). Five patients were diagnosed with frontal sinusitis prior SDE. Initially, three patients (27%) underwent burr hole aspiration and ten patients (83%) underwent craniotomy. In one patient both were done in the same session. Six patients were reoperated (50%). Weekly magnetic resonance imaging and blood tests were used for follow-up. All patients received antibiotics for at least 6 weeks. There was no mortality. Mean follow-up period was 10 months.

Conclusion: Interhemispheric SDEs are rare, challenging intracranial infections that have been related to high morbidity and mor-tality rates in the past. Both antibiotics and surgical interventions play role in treatment. Careful choice of surgical approach and repeated surgeries if necessary, accompanied by appropriate antibiotic regimen, leads to good prognosis reducing morbidity and mortality.

Figure 1

(a) Parasagittal craniotomy extending to contralateral side. Burr holes are placed on either side of the superior sagittal sinus. (b) Sinus-based opening of the dura and dissection of the interhemispheric fissure helped us to evacuate the empyema. (c) Leyla retractor was used when necessary to reach interhemispheric space.

Figure 2

Pre-operative and post-operative MRIs of a patient with multiloculated interhemispheric subdural empyema treated with craniotomy.

Figure 3

(a) First MRI of the patient when he became symptomatic showing interhemispheric SDE. (b) Initial MRI of the patient showing temporal SDE. (c and d) Follow-up MRI of the patient 2 months after discharge, without residual empyema can be seen both in interhemispheric space and temporal lobe.

Figure 4

(a) Initial MRI of the patient, after motor deficit developed. (b) First post-operative MRI immediately after surgery of the patient revealed no further pus collections. (c) Post-operative 1 week MRI showing enlargement of the collection more posteriorly. (d) Control MRI in post-operative 6^th month showed no residual collection.