Background. The incidence of sphenoid sinusitis has decreased significantly since the pre‐antibiotic era. Intracranial complications from isolated sphenoid sinusitis are rare but have a high morbidity and mortality. Methods. A case of intracranial extension of sphenoid sinusitis in a 64‐year‐old woman is reported. Results. A 64‐year‐old woman was initially seen unconscious with bacterial meningitis and cerebrospinal fluid (CSF) fistula. Imaging suggested sphenoid sinusitis with intracranial extension. She underwent a sinus drainage procedure, was placed on antibiotic therapy, and underwent a definitive sphenoid sinus obliteration. The patient made a satisfactory recovery. Conclusions. Despite the low incidence of intracranial complications of sphenoid sinusitis, the potential morbidity and mortality from such complications is high. We advocate aggressive management consisting of antibiotic therapy, sinus drainage, and definitive CSF fistula repair. © 1995 Jons Wiley & Sons, Inc.