Drain placement plays a role in supratentorial subdural empyema following chronic subdural hematoma evacuation ¹⁾.

Empyema occurs in 2% of patients, especially when the drain is left in place more than 3 days ²⁾.

The presence of hematoma capsule carries the risk of development of an infectious focus. The most frequent major surgical complications were intracerebral hemorrhage and subdural empyema (n 8, 2.1% each) ³⁾.

Five (9.1%) of 55 patients operated died either from empyemas (three) or rebleedings (two) ⁴⁾.

A 54-year-old male presented with 20 hour duration of headache, fever, and progressive deterioration of consciousness. He had undergone two burr-holes craniostomy and closed system drainages two times in a month for right fronto-parietal chronic subdural hematoma (CSDH). He presented to emergency department 10 days after the last surgery. There was history of closed head trauma 4 months ago and no skull fracture. Neurological examination revealed a Glasgow Coma Scale score of 10 (E3, V2, M5) and left side hemiparesis (3/5). Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated subdural collection in the same localization of the prior SDH.

With a possible diagnosis of SDE, he underwent emergent surgery under local anesthesia using the same burr holes to evacuate the subdural collection. At operation, a very thick capsule was seen around the lesion. A yellowish purulent material was drained with puncturing of the capsule. The empyema cavity was irrigated with sterile saline solution until the returning fluid was clear, and drains were placed in the subdural space for 2 days. Postoperatively he was alert and the hemiparesis resolved rapidly on postoperative day-1. Culture of the subdural fluid identified methicillin-resistant Staphylococcus epidermidis. He was treated with intravenous vancomycin and meropenem for 6 weeks. He was on prophylactic antiepileptic treatment since the first subdural hematoma drainage. He recovered fully and repeat MRI at 6 weeks follow-up did not show any recurrence of pus collection. He has been followed up in the outpatient clinic for 2 years ⁵⁾.

A 71-year-old man developed a large multi-loculated subdural empyema following the evacuation of a chronic subdural haematoma. The pockets of pus were successfully evacuated endoscopically via the burr holes resulting in good recovery and no re-accumulation. The advantages of this technique and the difficulties encountered during this procedure are discussed ⁶⁾.

Two patients with postoperative subdural empyema following burr hole evacuation of chronic subdural haematoma are reported, both caused by Propionibacterium acnes. The need to consider this diagnosis in patients developing recurrent symptoms after surgical drainage of chronic subdural haematoma is emphasized ⁷⁾.