Subdural empyema is a neurosurgical condition, which requires emergency surgical drainage and subsequent medical therapy. In order to evacuate the pus, burr hole placement or craniotomy may be used to treat the subdural empyema. The preferred surgical mainstay of treatment for subdural empyema is craniotomy. A wide craniotomy allows a wide exposure of the area, adequate exploration, and better evacuation of the infected material and decompression of the underlying cerebral hemisphere, thereby improving the outcome.^[1][2]

Subdural empyema is a neurosurgical condition, which requires emergency surgical drainage and subsequent medical therapy. Early diagnosis, appropriate surgical drainage and adequate antibiotic therapy are the key to a favorable outcome. Following the surgical procedure, the pus from the empyema should be sent for aerobic and anaerobic cultures, in order to determine the most adequate antimicrobial therapy. Except in rare situations, where there are contraindications for surgery, or the mortality risk is greater, subdural empyema should nearly always be treated surgically. Other concomitant situations, such as sinusitis, otitis, and mastoiditis, may also require surgical intervention.^[1][2]

In order to evacuate the pus, there are two surgical procedures used in the treatment of subdural empyema:

• Burr hole placement
• Craniotomy

Generally, burr hole placement is performed in septic patients with confirmed parafalcine empyemas, or when the patient is considered too frail to undergo the craniotomy.^[3] In the burr hole placement technique, a previous imaging study accurately localizes the collection of pus to be evacuated. It is associated with a higher rate of recurrence of the empyema, compared to the craniotomy procedure, and may also lead to secondary injury of the cortex, possibly exacerbating the infection.^[3][4]

The preferred surgical mainstay of treatment for subdural empyema is craniotomy. A wide craniotomy allows a wide exposure of the area, adequate exploration, and better evacuation of the infected material and decompression of the underlying cerebral hemisphere, thereby improving the outcome.^[1][2] A possible complication of craniotomy is the higher probability of damage to the bridging veins during the procedure. The following video demonstrates evacuation of pus from subdural empyema via craniotomy:^[5]

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