PMC9699880_01
(a) Coronal view of computed tomography brain without contrast demonstrating a right frontal contusion with associated subarachnoid hemorrhage at the site of future abscess. (b) Three-dimensional reconstruction of computed tomography face which reveals the complex facial fractures as well as the right-sided orbital fractures.
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F1
She had computed tomography (CT) imaging as part of the trauma work up which revealed a right sided contusion, traumatic subarachnoid hemorrhage [Figure 1a], and right frontal and parafalcine subdural hematomas. The CT also revealed multiple facial fractures [Figure 1b], including comminution in all walls of the orbit, including superior, lateral, medial, and inferior orbital wall fractures with trace extraconal air medially and evidence of a retrobulbar hematoma of the right globe [Figure 1a]. There were also bilateral nasal bone fractures, a comminuted right zygomaticomaxillary complex fracture, a right nasoethmoid fracture, comminuted right frontal and temporal skull fractures, as well as right sphenoid wing and cribriform plate fractures [Figure 1b].
(a and b) Magnetic resonance image brain with diffusion sequences showing restricted diffusion of a right frontal collection, suspicious for abscess, as well as (c) T1 axial sequence with gadolinium (right) showing a right frontal rim enhancing collection.
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F2
A magnetic resonance image (MRI) of the brain with contrast was obtained which demonstrated a right frontal heterogeneous collection with rim enhancement and central restricted diffusion highly suspicious for abscess [Figures 2a-c].
(a) Intraoperative picture showing dural tear (arrow) at the anterior skull base overlying the orbital roof fracture. (b) Intraoperative picture revealing a displaced fracture (arrow) of the right orbital roof.
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F3
At this point, it was noted that there was a dural defect under the abscess, which was overlying the orbital roof fracture and likely represented a conduit for bacterial spread [Figure 3a]. The dura was dissected along the anterior skull base down to the orbital roof, which was noted to be irregular and elevated into the dura at the site of the prior fracture [Figure 3b].
Intraoperative photographs. (a) Patient draped and supine after right frontal craniotomy and evacuation of abscess, status post dural closure with pericranium, and synthetic dural sealant. (b) Bone flap replaced with titanium plate fixation after drainage of abscess.
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F4
The dural incision was then closed and the craniotomy flap plated [Figures 4a and b].