Mini-Invasive Neurosurgical Treatment of Subdural Empyema: A Two-Patient Case Series.

BACKGROUND: Subdural empyema is a neurosurgical emergency traditionally managed with craniotomy and prolonged intravenous antibiotic therapy. Minimally invasive approaches may represent an alternative in selected cases, particularly when combined with timely diagnosis and targeted antimicrobial treatment. PATIENTS: We report two cases of subdural empyema treated with minimally invasive burr-hole evacuation. CASE 1: A 22-year-old man with developmental anomalies and postischemic stroke history presented with intermittent high fever for 2 weeks. Rapid neurological deterioration over 24 hours led to coma (Glasgow Coma Scale 5). Cranial computed tomography (CT) revealed a right-sided subdural empyema with significant mass effect. Emergency burr-hole evacuation was performed, followed by broad-spectrum antibiotics later tailored to Staphylococcus aureus. CASE 2: A 40-year-old man presented with hypertensive intracranial syndrome and febrile episodes for 1 week. CT and magnetic resonance imaging revealed a left hemispheric subdural collection suggestive of empyema, likely secondary to otitis media from suspected Streptococcus anginosus. Burr-hole evacuation and empiric triple antibiotic therapy were initiated. RESULTS: In both cases, postoperative imaging confirmed complete evacuation without residual collection. The first patient required prolonged intensive care with gradual neurological improvement over several weeks, whereas the second patient achieved immediate postoperative recovery. At 2-year radiological follow-up, no recurrence was observed in either patient. CONCLUSION: Minimally invasive burr-hole evacuation, combined with culture-guided antibiotic therapy, can be effective in selected cases of subdural empyema, yielding favorable clinical and radiological outcomes.