\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[polish,ngerman,romanian,english]{babel}



\usepackage{float}








\begin{document}

\title{Subdural empyema due to mixed infections successfully treated medically:
a case report with review literature.}



\author[1]{Mostafa Meshref}%
\author[2]{Anas  Nourelden}%
\author[3]{Alaa  Elshanbary}%
\author[3]{Yossef  AbdelQadir}%
\author[2]{Mohamed  Zaazouee}%
\author[4]{Khaled  Ragab}%
\author[5]{Sarya Swed}%
\affil[1]{Al-Azhar University}%
\affil[2]{Al-Azhar University Faculty of Medicine}%
\affil[3]{Alexandria University Faculty of Medicine}%
\affil[4]{Minia University Faculty of Medicine}%
\affil[5]{University of Aleppo Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 23, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Subdural empyema is a rare intracranial infection with an accumulation
of purulent material between the dura and arachnoid matter. We report a
case of 17 years old presented with altered conscious level .CSF
analysis showed increased WBCS. His situation has improved after
treating by acyclovir, ceftriaxone, vancomycin and dexamethasone.%
\end{abstract}%



\sloppy


Subdural empyema due to mixed infections successfully treated medically:
a case report with review literature.

Mostafa Mahmoud Meshref\textsuperscript{1}, Anas Zakarya
Nourelden\textsuperscript{2,6}, Alaa Ahmed
Elshanbary\textsuperscript{3,6}, Yossef Hassan
AbdelQadir\textsuperscript{3,6}, Mohamed Sayed
Zaazouee\textsuperscript{4,6}, Khaled Mohamed
Ragab\textsuperscript{5,6*}, Sarya Swed\textsuperscript{7}*.

\textsuperscript{1}MSc neurology, Al-Azhar University, Cairo, Egypt.

\textsuperscript{2}Faculty of Medicine, Al-Azhar University, Cairo,
Egypt.

\textsuperscript{3}Faculty of Medicine, Alexandria University,
Alexandria, Egypt.

\textsuperscript{4}Faculty of Medicine Al-Azhar University, Assiut,
Egypt.

\textsuperscript{5}Faculty of Medicine, Minia University, Egypt.

\textsuperscript{6}International Medical Research Association (IMedRA)

\textsuperscript{7}Faculty of Medicine , Aleppo University , Aleppo ,
Syria

*Corresponding author: Sarya Swed

Affiliation: Faculty of Medicine , Aleppo University , Aleppo , Syria

Tel: +963936500813

Email: saryaswed1@gmai.com

Abstract

Subdural empyema is a rare intracranial infection with an accumulation
of purulent material between the dura and arachnoid matter. We report a
case of 17 years old presented with altered conscious level .CSF
analysis showed increased WBCS. His situation has improved after
treating by acyclovir, ceftriaxone, vancomycin and dexamethasone.

Keywords: Subdural empyema, viral infection, bacterial infection,
medical treatment, Meningeal irritation.

Introduction:

Subdural empyema (SDE) is a collection of pus between the dura and
arachnoid layers of the meninges (1). It is a rare infection of the
brain, and it is an almost fatal condition if left untreated, but Since
using antibiotics, the mortality rate has decreased and now ranges from
14\% to 28\% (2,3). In infants, it complicates neonatal meningitis, but
in older children, it develops mostly as a consequence of ear, sinus
infection, or spread from hematogenous source (1,3--8). In males, SDE is
more frequently seen in males and it is the most commonly encountered
intracranial complication of infection(4,5), The patient usually
presents with fever, sinusitis, and neurological deficits with less
frequent some other symptoms include headache and seizure with
alteration of the level of consciousness (1,6--10). Laboratory
investigations vary from blood to imaging. Computed tomography (CT) and
magnetic resonance imaging (MRI) are the most important (4,11). Also,
white blood cell count, erythrocyte sedimentation rate, and C-reactive
protein level may be helpful. Imaging is recommended for every patient
suspected to have a subdural abscess. In some cases, when the diagnosis
by CT and MRI is unclear, hollow screws have a diagnostic value (12).
Broad spectrum antibiotics are usually the first line management and
they may be enough to control the infection (13--15). However, surgical
intervention must be considered if the antibiotics fail to control or
with other surgery indications (16,17).The most common surgical
procedures are craniotomy and burr holes (13,14). If the surgical
intervention has been done within 72 hours, the chance for disability is
10\% compared to 70\% when done after 72 hours (18).

Because of its rarity, many doctors may not have seen a case in recent
years. Therefore, the topic should be re-visited to remind them to be
aware of it. Also, it is difficult to distinguish from meningitis; hence
the attending clinician must have a high suspicion index.

In this report, we presented subdural empyema case that was successfully
treated by medical treatment in our hospital. Also, we systematically
summarized the previous published case reports about SDE.

Literature review

We searched for published case reports in four electronic databases:
PubMed, Scopus, Web of Science, and Cochrane Central Register of
Controlled Trials (CENTRAL) in October 2020 using the following query:
(''Empyema, Subdural''{[}Mesh{]}). We included all English case reports
about subdural empyema in adolescent patients (10-19 years).

Since 1990, approximately 35 studies with 53 patients have reported
similar cases in this specific age group; most of them were males
(86.7\%). The observed pattern of predisposing events is sinusitis,
otitis media, or an upper airway infection. Patients have usually
suffered from fever, headache, and drowsiness. The neurological
manifestations started with nuchal rigidity (17 \% of cases), hemiplegia
(11.3 \% of cases), or seizures (18.8 \% of cases).

Details of each case and the organism isolated from culture and the
outcome are presented in table 1.

Case report

A 17 years old male patient referred to our hospital. He had no history
of co-morbid illnesses. At first sight, he seemed distracted and altered
conscious level was noted. By history, seven days ago, the condition was
started with a headache and low-grade fever without apparent septic
focus; no tonsillitis or upper respiratory tract infection (URTI). The
patient came to our hospital with his family member (from whom the
history had been taken). They complained that the patient had a fever,
which was not improved by analgesics associated with malaise and
disturbing consciousness level in the form of drowsiness and confusion;
the patient was inattentive and disoriented to time, place, and persons.
On examination, the patient was feverish (38.5), drowsy, confused, and
no focal neurological deficit with positive meningeal irritation signs;
neck stiffness, positive kerning's and stretch leg signs. C.T Brain at
once showed mild diffuse brain edema of the right cerebral hemisphere
with a suspected thin rim of overlying extra-axial fluid collection,
with mildly expanded frontal sinus suspected mucocele formation and
obliteration of the sphenoid, right ethmoid sinuses as well as right
mastoid air sinuses~(Figure 1).~We asked for a lumbar puncture (after
taking consent from the family) to obtain a CSF sample for analysis.
Septic screen samples; urine analysis and cultures, nasal swab, axillary
culture, throat culture, blood culture, and sputum culture were also
withdrawn. Routine labs were withdrawn as well, including complete blood
count with differential, kidney and liver functions, and electrolyte
levels.

Few days later, the results of CSF analysis showed that CSF was clear
colorless fluid, RBCs 400 cells/cmm, WBCs 66 cells/cmm (neutrophils
30\%, lymphocytes 65\%, mononuclear cells 5\%), CSF glucose was 4.8
mmol/liter which is high (normal range 2.2-3.9 mmol/liter), CSF protein
was 52.7 mg/dl which is also high (normal range 15-45 mg/dl). Also, CSF
cultures were negative for any bacterial growth, including gram bacteria
and acid-fast bacilli). Acid-fast bacilli PCR is also negative.

Septic screen results also were negative to any bacterial growth. The
rest of the tests were normal except for increased W.B.Cs count 14x103
with increased neutrophils 87.9.

Low-grade fever at first, high glucose level, and predominance of
lymphocytes in CSF are evidence of viral infection. In addition to,
mucocele and the presence of sinusitis are bacterial infections, so a
treatment that covering possible causes of CNS infection was initiated;
acyclovir (10 mg/kg IV ter in die (tid); three times a day), ceftriaxone
(2 gm IV bis in die (bid); twice a day), vancomycin (750 mg IV bid), and
dexamethasone (4 mg IV quater in die (qid); four times a day).

The next morning, an MRI brain with contrast was conducted and showed
mild diffuse thickening of the pachy/leptomeninges overlying the right
cerebral hemisphere with mild intervening fluid collection seen
eliciting low signal on t1 and high signal on t2 weighted images with
evidence of diffusion restriction, features suggestive right-side
meningitis with mild subdural empyema. Evidence of right-sided mild mass
effects that was manifested by effacement of the underlying cortical
sulci with mild compression on the right lateral ventricle. In addition
to that, there was obliteration and mildly expansion of frontal sinus
showing a high signal on both t1, t2 weighted images, likely
representing mucocele formation. Also, obliteration of the sphenoid,
right ethmoid sinuses and right mastoid air cells has occurred~(Figure
2).

At the end of the second day after admission, the patient developed
serial attacks of generalized tonic colonic fits, controlled by giving
loading phenytoin (15 mg/kg), after that, we kept him on levetiracetam
(500 mg po BID). Also, EEG was done which showed slowness activity
figure (3). The patient's condition improved on the 5th day regarding
consciousness level, and no more fits had occurred. The patient was
continued on the same treatment measures, and a follow-up MRI brain with
contrast was done after one week, which showed a reduction of the
right-sided meningeal enhancement, with the same picture of the subdural
collection with an improvement of the mass effects (Figure 4).

The patient was continued on the same treatment plan for three weeks
with decreased dexamethasone doses till the stop. A follow-up MRI brain
with contrast was done after 3 weeks, which showed considerable
regression of the meningeal thickening and enhancement for the right
subdural empyema (Figure 5).

The patient was discharged with marked improvement up to his normal
state with no complaints.

Discussion:

This case report presents a patient with subdural empyema resulted from
a mixed bacterial and viral infection. The patient suffered from
sinusitis seven days before our investigation. The CSF analysis showed
an increasing number of WBCs (66 cells/cmm) and 30\% neutrophils, and
the CT scan showed mild diffuse brain edema of the right cerebral
hemisphere with suspected mucocele formation, which is considered
evidence of bacterial infection. Also, CSF analysis showed an increase
in the number of lymphocytes 65\% and glucose 4.8 mmol/liter which is
considered evidence of viral infection. Our case showed a thin rim in CT
and no significant midline shift in MRI, so it is considered a mild
case. Although surgery is the first line in the treatment of SDE, there
is a widely unutilized option to use antibiotics in mild cases (18, 19),
So we treated our patient medically with acyclovir (10 mg /kg IV tid)
for viral infection; ceftriaxone (2 gm IV bid), vancomycin (750 mg IV
bid) for bacterial infection and dexamethasone (4 mg qid). The treatment
was effective, and the patient had recovered with no severe side effects
or disability.

What makes this case unique is a mixed infection; the patient was also
treated medically, while a limitation was no PCR analysis for causative
organisms. The case was diagnosed as SDE depending on the clinical
history (fever, disturbed conscious level, meningeal irritation signs,
fits and preceding infection), CSF findings (which showed the proof of
mixed infection) and MRI brain findings. Also, there was evidence of EEG
changes in the form of slowness activity which is going with Mauser H.W
et al. as they found multiple EEG changes which may occur with SDE cases
including diffuse slowness (19). Thus, diagnosis depends only on
clinical history, signs, labs, EEG and radiology findings.

Ruth et al. concluded that a nonsurgical strategy might be considered
for patients with a good clinical condition with a minor shift from the
midline on radiology results (21). Musa et al. reported evidence of
pre-surgical treatment with I.V chloramphenicol and metronidazole for
four weeks and resulted in an increase in a Glasgow coma scale from 8/15
to 15/15 with no seizures (23). Subdural empyema had reported getting
negative in culture test; a case series by Madhugiri et al. consisted of
27 patients with a mean age of 10 years reported that 26\% of patients
get negative in culture test (22).

Based on our case, physicians should consider the treatment of viral and
bacterial infections in similar cases. Medical treatment of mild SDE
patients can be effective and safe. Future research is needed to
investigate the merits and limitations of using medical treatment alone
in SDE with mild and moderate cases. In conclusion as there were
multiple conflicts in differentiation between SDE and meningitis, all
attending doctors must suspect it. Start medical treatment as soon as
possible for all suspected cases depending on the clinical, radiological
and lab findings. Early intervention in those cases whether medical or
surgical according to case degree can improve the patient outcomes and
lead to good prognosis. In spite our case showed marked improvement only
on using medical treatments. Multiple researches should be conducted for
clarification and putting criteria for either medical or surgical
treatments for SDE patients.

Acknowledgements

N/A

Conflicts of interest

There is no conflict of interest.

Funding

N/A

Ethical approval

Consent to case study report given by Nassau University Medical Centre,
NY

Consent for publication

We obtained all appropriate patient consent forms. In the form, the
patient has given his consent for his images and other clinical
information to be reported in the journal. The patient knew that his
name and initials would not be published, and due efforts will be made
to conceal their identity, but anonymity cannot be guaranteed.

Guarantor

Sarya Swed

References:

1. Gormley WB, del Busto R, Saravolatz LD et al. Cranial and
intracranial bacterial infections. Neurol Surg. 1996;5:3191--322.

2. Hlavin ML, Kaminski HJ, Fenstermaker RA, White RJ. Intracranial
suppuration: A modern decade of postoperative subdural empyema and
epidural abscess. Neurosurgery. 1994 Jun;34(6):974--81.

3. Nathoo N, Nadvi SS, Van Dellen JR, Gouws E. Intracranial subdural
empyemas in the era of computed tomography: A review of 699 cases.
Neurosurgery. 1999 Mar;44(3):529--36.

4. Rich PM, Deasy NP, Jarosz JM. Intracranial dural empyema. Br J
Radiol. 2000 Dec;73(876):1329--36.

5. Demaerel P. A. J. Barkovich: Pediatric neuroimaging, 3rd edn. Eur
Radiol. 2001;11(11):2347--2347.

6. Quraishi H, Zevallos JP. Subdural empyema as a complication of
sinusitis in the pediatric population. Int J Pediatr Otorhinolaryngol.
2006 Sep;70(9):1581--6.

7. Tewari MK, Sharma RR, Shiv VK, Lad SD. Spectrum of intracranial
subdural empyemas in a series of 45 patients: Current surgical options
and outcome. Neurol India. 2004 Sep;52(3):346--9.

8. Greenlee JE. Subdural Empyema. Curr Treat Options Neurol. 2003
Jan;5(1):13--22.

9. Adame N, Hedlund G, Byington CL. Sinogenic intracranial empyema in
children. Pediatrics. 2005 Sep;116(3):e461-7.

10. Yilmaz N, Kiymaz N, Yilmaz C, Bay A, Yuca SA, Mumcu C, et al.
Surgical treatment outcome of subdural empyema: A clinical study.
Pediatr Neurosurg. 2006;42(5):293--8.

11. Weingarten K, Zimmerman RD, Becker RD, Heier LA, Haimes AB, Deck
MDF. Subdural and epidural empyemas: MR imaging. Am J Roentgenol. 1989
Mar;152(3):615--21.

12. Aldinger FA, Shiban E, Gempt J, Meyer B, Kreutzer J, Krieg SM.
Hollow screws: A diagnostic tool for intracranial empyema. Acta
Neurochir (Wien). 2013 Feb;155(2):373--7.

13. Feuerman T, Wackym PA, Gade GF, Dubrow T. Craniotomy improves
outcome in subdural empyema. Surg Neurol. 1989 Aug;32(2):105--10.

14. GLASS RL. Osteoplastic flap method in the treatment of subdural
abscess. J Neurosurg. 1947 Jul;4(4):391--3.

15. Mauser HW, Van Houwelingen HC, Tulleken CAF. Factors affecting the
outcome in subdural empyema. J Neurol Neurosurg Psychiatry. 1987
Sep;50(9):1136--41.

16. Mauser HW, Ravijst RAP, Elderson A, van Gijn J, Tulleken CA.
Nonsurgical treatment of subdural empyema. Case report. J Neurosurg.
1985 Jul;63(1):128--30.

17. Leys D, Destee A, Petit H, Warot P. Management of subdural
intracranial empyemas should not always require surgery. J Neurol
Neurosurg Psychiatry. 1986 Jun;49(6):635--9.

18. Renaudin JW, Frazee J. Subdural empyema - Importance of early
diagnosis. Neurosurgery. 1980 Nov;7(5):477--9.

19. Mauser H., Van Huffelen A., Tulleken CA. The EEG in the diagnosis of
subdural empyema. Electroencephalogr Clin Neurophysiol. 1986
Dec;64(6):511--6.

20. \selectlanguage{polish}Ş\selectlanguage{english}ahin S, Yazar U, Cansu A, Kul S, Kaya S, \selectlanguage{ngerman}Özdo\selectlanguage{polish}ğ\selectlanguage{english}an EB. Is Sinusitis
Innocent?-- Unilateral Subdural Empyema in an Immunocompetent Child.
Indian J Pediatr. 2015;82(11):1061--4.

21. Y\selectlanguage{ngerman}ücel ÖT, Ö\selectlanguage{romanian}ǧretmenoǧlu O. Subdural empyema and blindness due to
cavernous sinus thrombosis in acute frontal sinusitis. Int J Pediatr
Otorhinolaryngol. 1998;46(1--2):121--5.

22. Arifianto MR, Ma'Ruf AZ, Ibrahim A, Bajamal AH. Interhemispheric and
Infratentorial Subdural Empyema with Preseptal Cellulitis as
Complications of Sinusitis: A Case Report. Pediatr Neurosurg.
2018;53(2):128--33.

23. Balfour-Lynn LM. Subdural empyema due to Burkholderia cepacia: An
unusual complication after lung transplantation for cystic fibrosis. J R
Soc Med Suppl. 1997;90(31):59--64.

24. Banerjee AD, Pandey P, Ambekar S, Chandramouli BA. Pediatric
intracranial subdural empyema caused by Mycobacterium tuberculosis-a
case report and review of literature. Child's Nerv Syst.
2010;26(8):1117--20.

25. Derin S, Sahan M, Hazer DB, Sahan L. Subdural empyema and unilateral
pansinusitis due to a tooth infection. BMJ Case Rep. 2015;2015:2014--6.

26. Borovich B, Johnston E, Spagnuolo E. Infratentorial subdural
empyema: Clinical and computerized tomography findings. Report of three
cases. J Neurosurg. 1990;72(2):299--301.

27. Calik M, Iscan A, Abuhandan M, Yetkin I, Bozku\selectlanguage{polish}ş \selectlanguage{english}F, Torun MF. Masked
subdural empyema secondary to frontal sinusitis. Am J Emerg Med.
2012;30(8):1--4.

28. Conlon BJ, Curran A, Timon C V. Pitfalls in the determination of
intracranial spread of complicated suppurative sinusitis. J Laryngol
Otol. 1996;110(7):673--5.

29. Dolan RW, Chowdhury K. Diagnosis and treatment of intracranial
complications of paranasal sinus infections. J Oral Maxillofac Surg.
1995;53(9):1080--7.

30. Dunn B, McCalla C, Hiestand B, O'Brien MC. The pediatric headache
that would not go away. Pediatr Emerg Care. 2013;29(12):1283--6.

31. harris1987\_2.pdf.

32. Heilbronn YD, Tovi F, Hirsch M, Ronen J. Subdural empyema of sinus
origin in children. Int J Pediatr Otorhinolaryngol. 1984;6(C):205--11.

33. Holland AA, Morriss M, Glasier PC, Stavinoha PL. Complicated
subdural empyema in an adolescent. Arch Clin Neuropsychol.
2013;28(1):81--91.

34. Jones BL, Wilcox MH. Subdural empyema due to Enterococcus faecalis.
Scand J Infect Dis. 1997;29(6):627--8.

35. Kageyama G, Park KC, Yoshimine Y, Yokota J. Extensive subdural
empyema treated with drainage and barbiturate therapy under intracranial
pressure monitoring: Case report. Neurol Res. 2000;22(6):601--4.

36. Kuczkowski J, Narozny W, Mikaszewski B, Stankiewicz C. Suppurative
complications of frontal sinusitis in children. Clin Pediatr (Phila).
2005;44(8):675--82.

37. Kwang Ong Y, Tan HKK. Suppurative intracranial complications of
sinusitis in children. Int J Pediatr Otorhinolaryngol.
2002;66(1):49--54.

38. Lefebvre L, Metellus P, Dufour H, Bruder N. Linezolid for treatment
of subdural empyema due to Streptococcus: case reports. Surg Neurol
{[}Internet{]}. 2009;71(1):89--91. Available from:
http://dx.doi.org/10.1016/j.surneu.2007.06.083

39. Manjila S, Singh G, Ndubuizu O, Jones Z, Hsu DP, Cohen AR.
Endovascular plug for internal carotid artery occlusion in the
management of a cavernous pseudoaneurysm with bifrontal subdural
empyema: Technical note. J Neurosurg Pediatr. 2017;20(3):239--46.

40. Millar JS, Choksey MS. Case of the month: Size is not important. Br
J Radiol. 1996;69(817):87--8.

41. Mitsuoka H, Tsunoda A, Mori K, Tajima A, Maeda M. Hypertrophic
Anterior Falx Artery Associated with Interhemispheric Subdural Empyema:
Case Report. Neurol Med Chir (Tokyo). 1995;35(11):830--2.

42. Morgan DW, Williams B. Posterior fossa subdural empyema. Brain.
1985;108(4):983--92.

43. Nica DA, Moroti-Constantinescu R, Copaciu R, Nica M.
Multidisciplinary management and outcome in subdural empyema - A case
report. Chir. 2011;108(5):673--6.

44. Pattisapu J V., Parent AD. Subdural empyemas in children. Pediatr
Neurosurg. 1987;13(5):251--4.

45. \selectlanguage{polish}Ş\selectlanguage{english}eng\selectlanguage{ngerman}ül G. \selectlanguage{polish}İ\selectlanguage{english}nfratentoryal Subdural Ampiyem. Turk Neurosurg.
2009;19(2):200--2.

46. Salunke PS, Malik V, Kovai P, Mukherjee KK. Falcotentorial subdural
empyema: Analysis of 10 cases. Acta Neurochir (Wien).
2011;153(1):164--9.

47. Tankhiwale SS, Katkar VJ. Subdural empyma due to Mycobacterium
fortuitum in a non-HIV patient. Indian J Med Microbiol.
2014;32(4):446--8.

48. Teelin K. New-onset Seizures in a 14-year-old Boy. 2017;

49. Teng HW, Chen CY, Chen HC, Chung WT, Lee W Sen. Fusobacterium
septicemia complicated by cerebral subdural and epidural empyemas: A
rare case of lemierre syndrome. J Emerg Med {[}Internet{]}.
2012;43(4):671--3. Available from:
http://dx.doi.org/10.1016/j.jemermed.2010.04.033

50. Waseem M, Khan S, Bomann S. Subdural Empyema Complicating Sinusitis.
J Emerg Med. 2008;35(3):277--81.

51. arifianto2017.

52. banerjee2010\_2.

53. Martines F, Salvago P, Ferrara S, Mucia M, Gambino A, Sireci F.
Parietal subdural empyema as complication of acute odontogenic
sinusitis: A case report. J Med Case Rep. 2014;8(1):1--7.

54. Per H, Kumanda\selectlanguage{polish}ş \selectlanguage{english}S, G\selectlanguage{ngerman}ümü\selectlanguage{polish}ş \selectlanguage{english}H, \selectlanguage{ngerman}Öztürk MK, Ço\selectlanguage{polish}ş\selectlanguage{english}kun A. Meningitis and
Subgaleal, Subdural, Epidural Empyema Due to Pasteurella Multocida. J
Emerg Med. 2010;39(1):35--8.

55. westhout2007.

Figures:

Figure 1. CT Brain at presentation: Mild diffuse brain edema of the
right cerebral hemisphere with mildly expanded frontal sinus suspected
mucocele formation.

Figure 2. MRI brain with contrast at the next morning: Mild diffuse
thickening of the pachy/leptomeninges over lying the right cerebral
hemisphere with mild intervening fluid collection.

Figure 3. EEG sheet which showed slowness activity.

Figure 4. MRI brain with contrast after one week: Reduction of the right
sided meningeal enhancement, with the same picture of the subdural
collection but improvement of the mass effects.

Figure 5. MRI brain with contrast after 3 weeks: Appreciable regression
of the meningeal thickening and enhancement and for the right subdural
empyema.

Table 1: Summary of the previous case reports \textsuperscript{21--56}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-4/Figure-4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-5/Figure-5}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

