A 63-year-old Caucasian male sustained a right-sided subdural hematoma, subarachnoid hemorrhage, and temporal lobe hemorrhagic contusion after a fall with head strike. Initial unenhanced CT of the head showed a multicompartmental hemorrhage with mild edema surrounding the intracerebral hemorrhage (ICH). No skull fractures were visualized. The patient was managed nonoperatively and discharged home with no neurological deficits 2 days after presentation. Two weeks later he presented to the emergency department with worsening headaches and altered sensorium. Unenhanced CT of the head showed markedly increased edema in the right temporal lobe.  MRI of the brain demonstrated a rim-enhancing lesion with internal diffusion restriction in the location of the prior hemorrhagic contusion. MR spectroscopy of the lesion was suggestive of an intracerebral abscess.

In retrospect, the patient’s initial CT showed partial opacification of the right mastoid air cells and tympanic cavity. It should be assumed that all trauma patients with opacified mastoid air cells have a temporal bone fracture until proven otherwise [1]. We suspect this patient may have had contiguous spread of infection related to an occult temporal bone fracture. Literature review shows abscess formation beginning 0 to 20 weeks after initial ICH. Patients usually present with a fever, headache, and other signs of systemic infection. Characteristic abnormalities on diffusion-weighted imaging and MR spectroscopy can help differentiate cerebral abscess from other space-occupying lesions of the brain. After the cerebral abscess was identified in our patient, he was taken for surgical resection of the abscess and antibiotics were initiated. The patient had complete resolution of headaches and altered sensorium.