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Pneumocephalus: A Rare Complication of Mastoiditis and Cerebral Venous Sinus Thrombosis

A 19-year-old African American female who was 16 weeks’ pregnant (gravida 2, para 1) received oral antibiotics and pain medications from her obstetrician and primary care physicians for chronic otitis media. She presented to our emergency department with dizziness, fever and chills, nausea and vomiting, and 3 weeks of severe right frontal headache. Vital signs were temperature 38.5 C, heart rate 144 beats per minute, blood pressure 110/83, and respiratory rate 44. Physical and neurological examinations were unremarkable except for right ear drainage. Computerized brain venography revealed right mastoiditis with bony erosion (Figure 1) as well as cerebral venous sinus thrombosis (CVST) of the right jugular vein that extended intracranially into the sigmoid and transverse sinus. The thrombosed sinuses contained multiple air pockets (Figure 2). Magnetic resonance venogram confirmed absence of flow in the right transverse and sigmoid sinuses (Figures 3). Blood cultures grew Peptoniphilus indolicus and Bacteroides fragilis, both notorious gas-producing anaerobic bacteria. Emergent surgical debridement and intravenous meropenem and vancomycin resolved the patient’s symptoms. Because of the infectious etiology of her CVST, she was not anticoagulated. She is currently 25 weeks’ pregnant.