Bilateral Decompressive Craniectomy for Subdural Empyema: A Case Report

Intracranial subdural empyema (SDE) is a rare but life-threatening condition characterized by the rapid spread of purulent infection within the subdural space and a high risk of neurological deterioration. Despite significant improvements in neuroimaging, antimicrobial therapy, and surgical techniques, severe cases may progress to diffuse cerebral edema and refractory intracranial hypertension, challenging conventional management strategies. Surgical evacuation remains the cornerstone of treatment; however, the role of decompressive craniectomy in infection-related intracranial hypertension is not well established and is supported primarily by isolated reports. We present a case of fulminant SDE requiring bilateral decompressive craniectomy as a life-saving measure due to uncontrollable intracranial pressure. This case underscores the potential role of aggressive decompressive surgery in selected patients with severe inflammatory brain swelling secondary to intracranial infection and highlights the need for heightened clinical awareness and individualized surgical decision-making. While bilateral decompressive craniectomy remains exceedingly rare in the context of SDE, this report contributes to the limited body of literature and suggests that such an approach may be considered in extreme cases when standard surgical interventions fail to achieve adequate intracranial pressure control.