case_images: PMC10927190_01
case_images: Preoperative head contrast-enhanced computed tomography scan ("Parenchyma and soft structures" window, left; "Bone" window, right). (a) Axial sequence: There is evidence of extensive remodeling of the nasal and paranasal cavities, configuring the cocaine-induced midline destructive lesions setting, consisting of a whole nasal cavity, bilaterally fused with ethmoidal cells and maxillary sinuses. (b) Axial sequence: A right intraparenchymal temporopolar abscess (35 x 33 mm), with central hypodensity and peripheral contrast enhancement and massive perilesional edema; at the level of the posterior aspect of the orbital cavity, there appeared a contrast-enhancing collection, apparently spreading of the infective process (white arrow). (c) Axial sequence: There is a vast bifrontal hypodense extra-axial lesion with subdural empyhematous collection. (d) Sagittal view: A contrast-enhancing collection within the pterygopalatine fossa extends towards the posterior aspect of the orbital cavity and within the intracranial compartment, describing the presumed dissemination pathway of the infective process (white arrow).
case_images: SNI-15-42-g001.jpg
case_images: PMC10927190_01_SNI-15-42-g001.jpg
case_images: F1
case_images: Moreover, extensive remodeling of the nasal and paranasal cavities, recognizable as cocaine-induced midline destructive lesions (CIMDL), and a hyperdense collection in the posterior aspect of the right maxillary sinus, spreading beyond the sphenopalatine foramen and pterygopalatine fossa through the orbital cavity and intracranial compartment were detected [Figure 1].
case_images: Preoperative post contrast brain magnetic resonance imaging T1-weighted sequences: (a) Axial sequence: A significant contrast enhancement of the right pterygopalatine fossa (white arrow) in the context of the thickened contrasted right maxillary mucosa and the suppurative process extending beyond the right temporal pole. (b) Sagittal sequence, paramedian right: There is a wide subdural empyema in the frontal lobe, with central hyperintensity and peripheral contrast enhancing hyperintensity. It shows the spreading pathway of the infection through the rotundum foramen, which results in an enlarged and hyperintense (white arrow). (c) Sagittal sequence, mid pupillary right: there is an intra-axial temporopolar abscess at its largest diameter in the sagittal plane (40 x 20 mm) and the right side of the bilateral subdural empyema at the frontal lobe. Detail of the hyperintense pterygopalatine fossa in sagittal view (white arrow) and of a hyperintense collection within the posterior aspect of the right orbital cavity (dotted white arrow). (d) Coronal sequence: It shows the subdural empyema at its maximum extension on the coronal plane, characterized by strong peripheral hyperintensity, most pronunciation at the right frontal lobe, and the orbital spreading of the contrast-enhancing collection (white line).
case_images: SNI-15-42-g002.jpg
case_images: PMC10927190_01_SNI-15-42-g002.jpg
case_images: F2
case_images: Subsequent contrast-enhanced MRI of the head confirmed the presence of a round lesion on the right temporal pole, with central necrosis and peripheral ring contrast enhancement [Figure 2]. Indeed, the hypothesized dissemination pathway of the inflammatory process started from the maxillary sinus, proceeding through the sphenopalatine foramen toward the pterygopalatine fossa, and then upward through the inferior orbital fissure toward the posterior aspect of the orbital cavity and, lastly, spread posteriorly, and superiorly, through the superior orbital fissure, toward the middle cranial fossa [Figure 2].
case_images: Right frontal-temporal approach: (a) After performing a right frontal-temporal craniotomy, a yellowish fluid collection was sampled for cultural examination. The dura had a thick, reactive, and yellowish aspect, and a solid, parenchymatous lesion was appreciable with a net cleavage plan between empyema and healthy cerebral cortex (black arrow). (b) The empyema had a parenchymatous consistency and was also yellowish (black arrow). A significant phlogistic perilesional reaction was clear. The lesion was gradually and piecemeal evacuated. (c) After evacuating the empyema, a small right temporopolar corticectomy was performed (black arrow), and the content of the abscess capsule was aspirated and sent to the laboratory for cultural analysis. (d) After the piecemeal evacuation of the subdural empyema and aspiration of the temporopolar abscess, nervous structures, and Sylvian vein appeared well decompressed and pulsating. The reactive dura mater was replaced with a synthetic patch.
case_images: SNI-15-42-g003.jpg
case_images: PMC10927190_01_SNI-15-42-g003.jpg
case_images: F3
case_images: Therefore, minimal temporal corticectomy was performed, and the abscess capsule content was aspirated [Figure 3].
case_images: One-month-postoperative post contrast brain magnetic resonance imaging T1-weighted sequences: (a) Axial sequence: 1-month-postoperative imaging showed a critical reduction in the diameter of the temporopolar abscess, in its largest diameter on the axial plane (1.23 x 0.53 cm), due to surgery and subsequent surgery antibiotic therapy (white arrow). (b) Axial sequence: The subdural lesion in the bilateral frontal-basal area showed almost complete resolution in its largest diameter on the axial plane. There was a dural thickening due to the inflammatory reaction in the surgical bed on the right frontal-temporal side. (c) Axial sequence: Antibiotic therapy also successfully resolved the infection among the right pterygopalatine fossa (white arrow). (d) Coronal sequence: The subdural empyema was resolved in the right frontal-temporal dural thickening due to the surgical approach and fibrotic reaction. (e) Sagittal sequence, paramedian right: Net volumetric reduction of infective lesions on the intracranial compartment and within the pterygopalatine fossa and orbital cavity.
case_images: SNI-15-42-g004.jpg
case_images: PMC10927190_01_SNI-15-42-g004.jpg
case_images: F4
case_images: MRI confirmed that the inflammation resolved in the pterygopalatine fossa and orbital cavity and showed a meaningful reduction in diameter on the axial plane of the temporopolar abscess (1.23 x 0.53 cm). Moreover, the subdural empyema located bilaterally in frontal-basal areas showed almost complete resolution, as well as infection of the right pterygopalatine fossa [Figure 4].