High risk and low prevalence diseases: Cavernous sinus thrombosis.

INTRODUCTION: Cavernous sinus thrombosis (CST) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of CST, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: CST is a potentially deadly thrombophlebitic disease involving the cavernous sinuses. The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST, though other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications. Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies. The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes). Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy. Other CNs that may be affected include III, IV, and V. The disease may also affect the pulmonary and central nervous systems. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases. Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity. Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation. CONCLUSION: An understanding of CST can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

A Rare Intersection of Septic Cavernous Sinus Thrombosis and Subarachnoid Hemorrhage: Insights from the Case of a 70-Year-Old Patient.

We describe a rare and complex case of septic cavernous sinus thrombosis (SCST) in a 70-year-old patient who initially presented with ocular symptoms that rapidly progressed to severe intracranial vascular complications, including subarachnoid hemorrhage (SAH). Despite the use of broad-spectrum antibiotics and anticoagulants, the patient's condition deteriorated. SCST, often caused by sinus infections, presents a significant diagnostic and therapeutic dilemma, with mortality rates exceeding 20%. This report underscores the diversity of clinical presentations, ranging from mild headaches to severe cranial nerve deficits, that complicate diagnosis and treatment. The inability to detect any aneurysms in our patient using magnetic resonance imaging (MRI) and computed tomography angiography (CTA) may indicate an alternative pathogenesis. This could involve venous hypertension and endothelial hyperpermeability. This case illustrates the need for personalized treatment approaches, as recommended by the European Federation of Neurological Societies, and the importance of a multidisciplinary perspective when managing such intricate neurological conditions. Our findings contribute to the understanding of SCST coexisting with SAH.

Odontogenic Lemierre's syndrome with septic superior ophthalmic vein and cavernous sinus thrombophlebitis complicated by blindness and ophthalmoplegia.

Lemierre's syndrome is a triad consisting of oropharyngeal infection, internal jugular vein thrombophlebitis, and systemic embolisation typically involving lung and brain. Orbital involvement in this life-threatening condition is rare but potentially blinding and may be an indicator of intracranial involvement. We describe a case of odontogenic Lemierre's syndrome complicated by extensive orbital and intracranial septic venous thrombosis, with optic and cranial neuropathy resulting in monocular blindness and ophthalmoplegia. A multidisciplinary approach with abscess drainage, antibiotic and antithrombotic therapy, and close radiological monitoring was critical for preserving contralateral vision and neurological function.

Septic Cavernous Sinus Thrombosis Associated With Orbital Cellulitis: A Report of 6 Cases and Review of Literature.

PURPOSE: To describe risk factors, clinical parameters, treatment, and prognosis for patients with septic cavernous sinus thrombosis presenting with orbital cellulitis. METHODS: Retrospective case series of 6 patients identified with septic cavernous sinus thrombosis and orbital cellulitis confirmed by magnetic resonance imaging at a tertiary care center from January 1980 to December 2016. Medical records were reviewed for demographics, risk factors, symptoms, etiology, radiographic diagnosis, complications, treatments, and outcomes. In addition, a literature review was performed from 2005 to 2018, and 119 cases of septic cavernous sinus thrombosis confirmed by imaging were included for aggregate comparison. This study adheres to the tenets of the Declaration of Helsinki, and institutional review board approval was obtained. RESULTS: All 6 cases presented with headache, fever, ocular motility deficit, periorbital edema, and proptosis. The primary source of infection included sinusitis (n = 4) and bacteremia (n = 2). Identified microorganisms included methicillin resistant Staphylococcus aureus (n = 3) and Streptococcus anginosus (n = 1). All cases were treated with broad-spectrum intravenous antibiotics and anticoagulation, and one case underwent endoscopic sinus surgery. The mean time between initial presentation to diagnosis of cavernous sinus thrombosis was 2.8 days, and the average length of hospital admission was 21 days. The mortality rate was 0%, but 4 cases were discharged with neurological deficits including vision loss (n = 1) and ocular motility disturbance (n = 3). Literature review produced an additional 119 cases. CONCLUSIONS: Early diagnostic imaging with contrast-enhanced CT or MRI should be initiated in patients with risk factors and ocular symptoms concerning for cavernous sinus thrombosis. Treatment entails early administration of broad-spectrum intravenous antibiotics, anticoagulation, and surgical drainage when applicable.

Thiol-Disulfide Homeostasis in Cerebral Venous Sinus Thrombosis.

BACKGROUND: The objective of this study is to examine thiol-disulfide homeostasis in patients with cerebral venous sinus thrombosis. METHODS: Fifty-three patients diagnosed with cerebral venous sinus thrombosis and 80 healthy volunteers were included in the study. The native thiol and total thiol concentrations were measured with the newly developed automated method. In addition, their amount of disulfide bonds was calculated. RESULTS: The total thiol and native thiol levels of the patients with cerebral venous sinus thrombosis were significantly lower than the healthy volunteers (p = 0.001, p = 0.001, respectively). In terms of dynamic disulfide bond formation, there was no statistically significant difference between the groups (p > 0.05). A significant negative correlation was determined between native thiol and total thiol levels and the number of sinuses that had thrombosis (r = -0.136, p = 0.033; r = -0.141, p = 0.015, respectively). There was no correlation between National Institutes of Health Stroke Scale score and thiol-disulfide homeostasis parameters. CONCLUSIONS: This study is the first study to examine thiol-disulfide homeostasis in patients with cerebral venous sinus thrombosis. The thiol-disulfide balance is impaired under oxidative stress. This study revealed that this balance is disrupted in correlation with widespread thrombosis in patients with cerebral venous sinus thrombosis. Therefore, fortification of thiol deficiency with N-acetyl cysteine or alpha-lipoic acid can prevent the progress of thrombosis and can be beneficial in cerebral venous sinus thrombosis treatment.

Prognosis of septic cavernous sinus thrombosis remarkably improved: a case series of 12 patients and literature review.

PURPOSE: Septic cavernous sinus thrombosis (CST) is a rare complication of infections in the head and neck area. CST is notorious for its bad prognosis, with high mortality and morbidity rates described in literature. However, these rates are based on old series. We question whether the prognosis of CST is currently still as devastating. The primary purpose of this study is to assess the mortality and morbidity of CST. METHODS: Using the databases of all relevant specialties in our tertiary referral hospital, we collected all the patients treated for CST in the period 2005-2017. In addition, a PubMed search, using the mesh term 'cavernous sinus thrombosis', was performed. RESULTS: We found 12 patients with CST in the study period. Of the 12 patients, 11 survived and 9 recovered without any permanent deficits. Seven patients were treated with anticoagulation, and in none of the patients we saw hemorrhagic complications. In literature, older articles describe higher mortality rates (14-80%), but more recent articles report mortality and morbidity rates similar to our results. CONCLUSIONS: The prognosis of CST nowadays is more favorable than previously described. Anticoagulation seems to be a safe addition to antibiotic and surgical treatment, at least in patients without central nervous system infection.

[Septic thrombus of the cavernous sinus]. / Septicheskii tromboz kavernoznogo sinusa.

The present review was designed to represent modern views of the problem of etiopathogenesis, clinical features, diagnostics, and treatment of septic thrombus of the cavernous sinus with special reference to the currently available methods for the detection and management of this condition.

Ophthalmic artery occlusion with total ophtalmoplegia and anisocoria revealing cavernous sinus thrombosis.

AIM: To describe a case of ophthalmic artery occlusion associated with anisocoria and revealing a cavernous sinus thrombosis due to sinusitis. OBSERVATION:   A 48-year-old man with a history of diabetes presented acutely with loss of vision and proptosis in the left eye. Ophthalmologic examination concluded in a left ophthalmic artery occlusion with anisocoria and total ophthalmoplgia. Cardiac assessment was normal. Magnetic resonance imaging (MRI) revealed left ophthalmic artery and internal carotid occlusions, left cavernous and transverse sinus thrombosis and sphenoid sinusitis. The patient underwent extensive haematological and medical assessment to search for embolic sources and disease causing thrombophilia. The patient recovered from the thrombosis episode, but sustained permanent blindness. CONCLUSION: Ophthalmic manifestations may be the only signs revealing cavernous sinus thrombosis which must be usually suspected. Visual prognostic was very poor.

COMMUNITY ACQUIRED METHICILLIN SENSITIVE STAPHYLOCCUS AUREUS CEREBRAL ABSCESS IN A PREVIOUSLY HEALTH GENTLEMAN MIMICKING SIGNS OF CAVERNOUS SINUS THROMBOSIS-A UNIQUE PRESENTATION.

Central Nervous System (CNS) infections like meningitis and cerebral abscess caused by Staphylococcus aureus are usually seen in patients with neurosurgical interventions or immune compromised patients or patients with cardiac vegetation's. They are extremely rare in healthy patients. We report a case of a 44 year old Indian gentleman who was perfectly healthy with no known co morbidities, which presented with fever, neck stiffness and altered mental status. He had fulminant staph bacteraemia (as evidenced by persistently positive blood cultures) with meningitis and cerebral abscess. Extensive search was made to find the source of infection, but it was inconclusive. Isolated CNS Methicillin Sensitive Staphylococcus aureus (MSSA) infection in an apparently healthy patient is very rare. This gentleman presented with altered mental status, asymmetrical exophthalmos and multiple cranial nerve palsies. This case highlights the challenge of making early diagnoses of a brain abscess; since it has symptomology mimicking cavernous sinus thrombosis .This is due to the involvement of the cerebellopontine angle and extensive brain oedema and oedema of the retro bulbar tissues.

A rare localization of cerebral venous sinus thrombosis. Case report.

In this work the Authors report their experience on the treatment of a case of cavernous venous sinus thrombosis. The diagnosis is clinical and neuroradiological, CT, MRN, cerebral angiography and orbital venography have aided in establishing the diagnosis during life. Very interesting is the therapeutic approach.

Optic nerve sheath fenestration for the treatment of papilledema secondary to cerebral venous thrombosis.

A 16-year-old adolescent girl with multiple risk factors for thrombosis presented with acute onset of headache, decreased vision, and papilledema. Evaluation demonstrated cerebral venous thrombosis (CVT) involving the left transverse and sigmoid sinuses and left internal jugular vein. Following bilateral optic nerve sheath fenestration (ONSF), she experienced improvement in vision and resolution of papilledema. In selected cases, ONSF is an effective surgical option for the treatment of papilledema due to CVT after medical treatment has failed.

A case of cavernous sinus thrombosis with meningitis caused by community acquired methicillin resistant Staphylococcus aureus.

Septic cavernous sinus thrombosis is a rare clinical condition. Although Staphylococcus aureus is the most common pathogen causing septic cavernous sinus thrombosis [CST], it is an uncommon cause of meningitis. We report the first case of CST with meningitis in Hyderabad, Andhra Pradesh, caused by community acquired epidemic strain of Methicillin resistant staphylococcus aureus [MRSA], in a previously healthy individual with no risk factors. The patient recovered completely following treatment with Vancomycin. We consecutively reviewed all cases of community acquired staphylococcus aureus [CA-MRSA] with central nervous system involvement available in literature.

Concomitant rapidly growing aneurysm of intracavernous carotid artery and cavernous sinus thrombosis: Case report and review of the literature.

RATIONALE: Intracavernous infectious aneurysm (ICIA), represents a rare entity that is always described in the form of case reports in the literature. The coexistence of ICIA and cavernous sinus thrombosis (CST) is extremely rare and poorly understood. PATIENT CONCERNS: A 53-year-old female patient presented to our hospital with headache, nausea and fatigue for 3 weeks. She complained of blurry vision and drooping eyelids before admission. Neurological examination revealed bilateral decreased visual acuity, limitation of extraocular movements and decreased sensation of forehead. Brain magnetic resonance imaging (MRI) showed mixed signal intensities in both cavernous sinuses and expansion of right superior ophthalmic vein, suggesting the formation of CST. One month later, computed tomography angiography (CTA) confirmed a large aneurysm was attached to the left intracavernous carotid artery (ICCA). DIAGNOESE: This patient was diagnosed with ICIA and CST. INTERVENTIONS: She was administered with intravenous meropenem and vancomycin and subcutaneous injection of low molecular heparin for 4 weeks. OUTCOMES: One month later, her extraocular movement had significantly improved, without ptosis and conjunctival congestion. At 1-year follow-up, her ophthalmoplegia fully recovered. Fortunately, such large aneurysm did not rupture in spite of slight broadening. LESSONS: The coexistence of ICIA and CST is extremely rare. Contiguous infection from adjacent tissues is the foremost cause of ICIA. A repeated angiographic examination is recommended under enough anti-infective treatment due to the characteristics of rapid emergence and fast growth of infectious aneurysms.