Intracranial complications of acute sinusitis

Case contributed by Dr Ian Bickle

Presentation

Recently discharged after an episode of sinusitis. Returns to A&E 'flat'. Intubated.

Patient Data

Age: 35 years
Gender: Female
Modality: CT

Low attenuation in the inferior right temporal lobe, external internal capsule and in the cortex of the left parietal lobe. Thin bilateral subdural collections, measuring less than 1cm bilaterally. Minor effacement of the right frontal horn. No hydrocephalus.

The right maxillary, ethmoidal and sphenoid sinuses are opacified with fluid. No bony destruction. Mastoids normal.

Long filling defect in the sagittal sinus highly suspicious for a venous sinus thrombosis.

Modality: MRI

Enhancing bilateral subdural collections with internal diffusion restriction measuring upto 6mm in depth, consistent with subdural empyema

Acute infarct in the distribution of the anterior branch of the right MCA involving the temporal lobe, external capsule and centrum semiovale.

Focal left parietal lobe cortical infarct - non arterial in distribution. No hydrocephalus.

Filling defect in the sagittal sinus, as on the CT, which is more suggestive of thrombus.

Extensive pan-sinusitis with diffusion restriction suggestive of pus.

Fibre optic sinus surgery undertaken

Modality: Photo

Large amount of frank creamy pus within the sphenoid sinus.

The subdural collections were also drained by the neurosurgical team at the same visit to theatre.

Case Discussion

This case illustrates several of the complications associated with intracranial infection and that intracranial infection can occur in acute sinus infection.  This may even occur without direct intracranial extension from bony breach of the sinus.

This very ill patient has:

  • bilateral subdural empyemas
  • right MCA territory acute infarct 
  • partial thrombosis of the sagittal sinus thrombosis with a small left parietal cortical (likely venous) infarct
  • acute pan-sinusitis

This is all in keeping with the sequelae of CNS infection, secondary to acute sinusitis.

The MRI nicely illustrates DWI imaging in three ways:

  1. Acute cerebral infarction.
  2. Subdural collections, indicating this is pus not a hygroma.
  3. Pan-sinusitis with intense restriction suggesting pus.
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Case Information

rID: 45559
Case created: 30th May 2016
Last edited: 15th Mar 2017
Inclusion in quiz mode: Included

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