Presentation
Long-term sinusitis and recurrent fever.
Patient Data
MRI shows the multiloculate morphology of the intracranial epidural collection located in the right supraorbital region; the largest loculation measures 3.5 x 2.7 x 2.1 cm, with a volume of 10.3 cm3. This collection is hypointense on T1-weighted and hyperintense on T2-weighted images, with a surrounding membrane that enhances with contrast administration. The collection shows restricted diffusion most pronounced within the posterior loculation. There is edema in the right frontal lobe, with mass effect and partial compression of the frontal horn of the right lateral ventricle.
There is also right ethmoidal sinus inflammation and the relationship of the collection to the right ethmoid cells. Neurosurgical drainage confirmed intracranial epidural abscess.
An arachnoid cyst is present in the left middle cranial fossa, with CSF intensity, no solid component, and no enhancement.
There are several confluent focal areas of signal intensities (FASI) in the cerebellum and some minor lesions in the basal ganglia,
Case Discussion
Sinusitis complicated by intracranial extension remains a severe problem in clinical practice 1, 2. Intracranial epidural abscess or empyema refers to infection between the inner table of the skull and the dura mater 2. This patient had a good outcome with antibiotic therapy and neurosurgical drainage of the intracranial collection, which confirmed epidural empyema.
This patient has café-au-lait skin macules and a first-degree relative with neurofibromatosis type 1, which in combination with the FASI seen on the MRI, prompted an early diagnosis of the disease.
Case courtesy
- Hetevaldo Tavares de Lira – PGY-1, neurosurgery resident, Department of Neurosurgery.
- Sterfferson Morais, MD - PGY-3, Radiology Resident, Department of Radiology
- Antonio Rodrigues de Aguiar Neto, MD - Radiologist, Department of Radiology
- Hospital da Restauração – Recife, PE – Brazil