Parafalcine subdural empyema: The unresolved controversy over the need for surgical treatment

Abstract

Background: Parafalcine subdural empyema (SDE) is a rare entity consisting of pus accumulating below the longitudinal sinus, between the falx cerebri and the arachnoid layer covering the medial surface of the cerebral hemisphere. Its treatment strategy is controversial, but most clinicians have the general belief that appropriate treatment consists of prompt surgery combined with long-term antibiotic therapy. Nevertheless, six reports published in the 1980s provided evidence that antibiotic therapy alone is a safe and suitable option. The treatment strategies and outcomes of the 31 well-described cases previously published, in addition to our own, are discussed. Case Description: We report a 21-year-old female with a right-side parafalcine SDE who presented with fever, headache, generalized tonic-clonic seizures, and contralateral hemiparesis 3 weeks after undergoing sinonasal surgery. Despite clinical symptoms almost entirely abating after starting treatment with broad-spectrum antibiotics, magnetic resonance imaging performed during the 2nd and 3rd weeks showed progressive enlargement of the interhemispheric collection (from 4 cm3 to 30 cm3). We reflect on the treatment strategy chosen for this patient, who experienced a total recovery. Conclusion: A nonsurgical strategy for parafalcine SDE might be contemplated for patients with a good clinical condition and no major midline shift on neuroradiological studies, given their usual indolent course and the relative difficulty in reaching the interhemispheric fissure. Conversely, surgery should be contemplated when the collection significantly enlarges despite antibiotic therapy. When surgical drainage is added to antibiotics, broad- range 16S ribosomal DNA polymerase chain reaction of the empyema is recommended to identify the causative organism as pus cultures are usually sterile.

Parvimonas micra: A potential causative pathogen to consider when diagnosing odontogenic brain abscesses

“…Nevertheless, antibiotic therapy alone might be a safe and suitable option for patients with small lesions, particularly when they are multiple and located deep within the brain. [17,18] ere are even more doubts regarding the most appropriate antibiotic regimen. Penicillin, amoxicillin (±clavulanic acid), piperacillin (±tazobactam), cefoxitin, ceftriaxone, imipenem, meropenem, ciprofloxacin, clindamycin, and metronidazole have all been found effective for treating Pm.…”

Acute subdural empyema in the young COVID-19 patient- A case report

“…2 Contrary to the typical convexity SDEs, the tendency of pus to extend along the length of the falx below the longitudinal sinus and bridging veins makes parafalcine, or interhemispheric, SDEs relatively difficult-to-reach collections. 1 Headache, hemiparesis, pyrexia, meningism, epilepsy, and vomiting were the commonest presenting features, and at least four of these were found in the majority of patients. 3…”

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Subdural empyema (SDE) is a rare but potentially lifethreatening disease consisting of a pyogenic infection in the pre-formed space between the inner surface of the dura mater and the outer surface of the arachnoid layer. 1 The potential subdural space is relatively free over and between the cerebral hemispheres but restricted in the central basal region; hence most subdural empyemas are found either on the convexity or in the parafalx region. 2 Contrary to the typical convexity SDEs, the tendency of pus to extend along the length of the falx below the longitudinal sinus and bridging veins makes parafalcine, or interhemispheric, SDEs relatively difficult-to-reach collections.

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Falco-Tentorial Subdural Empyema – Reporting a Rare Entity

“…Surgical combined with empirical antibiotic treatment is the mainstay of treatment, although few cases can be treated by only medical management, when the clinical condition is not critical and there is no significant midline shift on imaging. [ 4 ] Surgical evacuation is always preferred when the patient has rapid deterioration of neurological status, or if the lesion is large and not amenable to medical management. Drainage can be via burr hole or craniotomy.…”