This week we highlighted a case of headache with an abnormal neurologic exam. We discussed that the patient would not meet the criteria for a Code Stroke given the patient presented >24 hours from symptom onset and therefore was outside the window for TPA therapy. All learners were concerned for an intracranial process, possibly an intracranial abscess. There was discussion about possible sinusitis or Pott’s puffy tumor with intracranial extension. We discussed the most appropriate head imaging and most agreed that CT with contrast was the first step. Learners also discussed the possibility of Cerebral Venous Sinus Thrombosis (CVST) and indications for CTV if head CT findings were abnormal.

Head CT showed a low-density collection along the entire left side of the falx (5mm thickness) and along the entire left hemispheric convexity (3 mm thickness). 6 mm rightward midline shift at the level of the septum pellucidum. Complete effacement of the basal cisterns consistent with downward transtentorial herniation. No intracranial hemorrhage. Complete opacification of frontal sinus and anterior left ethmoid air cells.

Imaging consistent with a subdural empyema likely secondary to intracranial extension of sinusitis. Neurosurgery took patient to OR for emergent craniotomy and empyema washout. Neurology also consulted and recommended MRI brain w/wo, MRV head to evaluate for CVST and MRA. Patient was loaded with Keppra and started on BID seizure prophylaxis prior to OR and admitted to PICU for q1 neuro checks. He was started on Ceftriaxone (meningitic dosing), vancomycin and flagyl. Blood culture grew Streptococcus intermedius.