Presentation
Seizure and left hemiparesis. History of acute sinusitis 2 weeks prior.
Patient Data
There is marked mucosal thickening involving the frontal, ethmoidal and sphenoidal sinuses with complete opacification of the right maxillary sinus. There is minor right periorbital edema. The mastoid air cells remain well pneumatized. No skull or calvarial fracture. No bony erosions.
The radiological findings are in keeping with acute sinusitis; predominantly in the right maxillary, frontal, sphenoidal and ethmoidal sinuses.
CT brain performed approximately two weeks after CT sinuses.
There is a large, extra-axial, subdural collection which measures 8 mm in maximal depth with marginal enhancement overlying the convexity of the right fronto-parietal lobe and posterior falx cerebri. There is loco-regional mass effect with mild bowing of the falx cerebri to the left, however there is no significant midline shift, hydrocephalus or tonsillar herniation.
Post contrast CT reveals diffuse cortical gyriform enhancement of the fronto-temporal lobe consistent with meningitis. Subtle hypodensity of the subcortical white matter of the right fronto-parietal region may represent vasogenic edema or less likely cerebritis.
No intraparenchymal enhancing lesions. No suspicious osseous lesions. The dural venous sinuses are clear within the limitations of this study. The paranasal sinuses and mastoid air cells are clear.
Imaging findings are suggestive of an extensive right supratentorial subdural empyema likely secondary to sinusitis.
Case Discussion
This young patient initially presented with fever, headache, nasal discharge and congestion. Sinusitis affecting the frontal, right maxillary, sphenoidal and ethmoidal sinuses was confirmed on CT scan. He was treated with antibiotics and nasal decongestant spray with clinical improvement and was subsequently discharged. He re-presented two weeks later with a seizure and acute onset left hemiparesis. A CT brain revealed an extensive right supratentorial subdural empyema with mass effect. An urgent neurosurgical review was obtained and the patient underwent surgical drainage of the subdural empyema.
Subdural empyema is a rare intracranial complication of frontal sinusitis 1. This case highlights the importance of early recognition and treatment of this potentially fatal condition.
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