Subdural empyema and frontal abscess complicating frontal sinusitis

Case contributed by Dr Derek Smith

Presentation

Two weeks unwell with worsening bilateral headache. New meningism; also fever, night sweats and weight loss.

Patient Data

Age: 15
Gender: Male

Enhancing collections around the crista galli, right frontal lobe, both temporal poles and right parafalcine extra-axial spaces.

Focal low attenuation (but no enhancement) in the right frontal lobe parenchyma; likely cerebritis / developing abscess.

Generalized sulcal effacement, but no significant midline shift. The basal cisterns and foramen magnum remain patent.

The frontal, anterior air cells, and right sphenoid sinuses are largely opacified. No focal bone defect is identified.

The patient underwent drainage of the frontal extra-axial collections via the sinus. Samples were positive for mixed Gram positive cocci.

An interval MRI confirmed worsening right frontal cerebritis, and extra-axial collections. Time of flight MRV was normal. Neurosurgical decompression of the subdurals was attempted via burr holes.

A contrast MRI was then performed.

MRI

Contrast MRI 1 week into presentation

Right parietal burr holes.

The subdural and parafalcine collections have increased in volume from the presentation CT, despite two operations for drainage. There is peripheral enhancement and restricted diffusion of these collections, as well as within the frontal, right sphenoid and right maxillary sinuses.

New from the CT is a 25 mm peripherally enhancing collection in the right frontal lobe, at the site of hypoattenuation. Although the peripheries demonstrate restricted diffusion, the center of the collection does not have low ADC value which would be expected for an abscess. (Follow up MRI however did "fill in" more consistent with pus).

There are also areas of FLAIR hyperintensity around the right frontal collection and in the right parietal and temporal cortices, suggesting further regions of cerebritis.

Case Discussion

Extensive and progressive intracranial extension from an anterior sinus infection.

Interval imaging demonstrated development of abscesses in the regions of cerebritis in spite of targeted antibiotic therapies, and further operative interventions were required to manage the infection.

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Case information

rID: 64439
Published: 22nd Nov 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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