Sinogenic Subdural Empyema in an Adolescent: Multifocal Disease, Decompressive Craniotomy, and Complete Recovery

Sinogenic subdural empyema is a rare and life-threatening complication of bacterial sinusitis. Non-specific symptoms tend to make early diagnosis and management challenging. We report the case of a previously healthy 16-year-old male who presented with a one-week history of upper respiratory symptoms and headache followed by a rapidly progressive neurologic deterioration. Multifocal subdural empyema was confirmed via multiparametric MRI. Cultures taken during neurosurgical intervention identified a polymicrobial etiology, including Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus constellatus,and Streptococcus intermedius, with the Streptococcus speciesbeing resistant to ceftriaxone and azithromycin. He underwent bifrontal craniotomies and endoscopic sinusotomies, followed by decompressive craniotomies for postoperative edema. In addition, he completed 59 days of culture-directed intravenous antimicrobial therapy. The patient recovered to his neurologic baseline. This case demonstrates the diagnostic pitfalls of early sinogenic subdural empyema in an adolescent, the role of multiparametric MRI over CT when there is suspected involvement of the intracranial space, and the potential for complete neurologic recovery despite a fulminant presentation requiring staged operative management.