The patient is a 57-year-old man with past medical history significant for epilepsy and left hemiplegia secondary to right-sided traumatic brain injury (TBI) 28 years prior to presentation. He presented with a 3-week history of depression, anxiety, and active suicidal ideation resulting in psychiatric admission to an outside hospital. He had three prior craniotomies for right subdural hematoma (SDH), one at the time of his TBI, one 8 years prior to presentation, and one 5 years prior to presentation. On follow-up imaging 3 years after his last craniotomy, he underwent head CT showing a small subacute SDH, which was managed nonoperatively [Figure 1]. He has no significant prior psychiatric history. His home medications include baclofen 20 mg, keppra 1000 mg BID, memantine 10 mg BID, gabapentin 600 mg TID, duloxetine 600 mg QD, quetiapine 50 mg PRN (for sleep), and simvastatin 40 mg. After a multiday admission at the outside hospital for depression with suicidal ideation, he underwent noncontrast MRI because of his prior history of craniotomy, revealing a 1.4 x 2.3 x 3.6 cm right-sided crescent-shaped collection consistent with subacute SDH [Figure 2]. There was no significant restricted diffusion on diffusion weighted image (DWI). The patient was at his neurologic baseline on presentation upon transfer to our hospital, and he was afebrile with a normal white count. The patient was brought to the operating room for evacuation of the presumed subacute SDH 21 h after admission to our hospital. During the craniotomy he was found to instead have an EDA. The craniotomy bone appeared infected and it was discarded. Epidural drain was left, and he was started on vancomycin, ceftriaxone, and metronidazole until tissue cultures grew ampicillin-sensitive enterococcus, at which point he was transitioned to 6 weeks of ampicillin-sulbactam. After surgery, the patient demonstrated elevated white blood cell count until day 3 of admission and elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) for the duration of admission. Outside of one elevated temperature of 99.5 F in the morning of the procedure, there were no preoperative signs of infection. The patient continued to function at his neurological baseline, and suicidal ideations and behavioral problems resolved by postoperative day 5. He was started on valproate 500 mg BID after surgery for seizure prophylaxis. He was discharged to a rehabilitation facility 13 days after admission. Cranioplasty with a PEEK implant was performed 6 months after this surgery. Three months after cranioplasty he was doing well, without evidence of infection on repeat MRI, and at his neurological baseline without any psychiatric problems.