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.

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.

Cavernous Sinus Thrombosis.

Cavernous sinus thrombosis is a potentially lethal subset of cerebral venous sinus thrombosis that may occur as a result of septic and aseptic etiologies. The overall incidence is estimated to be between 0.2 and 1.6 per 100,000 persons; and treatments include antibiotics, anticoagulation, corticosteroids, and surgery. Recent morbidity and mortality estimates are approximately 15% and 11%, respectively. Rapid identification and treatment are essential and may reduce the risk of poor outcome or death.

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.

Septic cavernous sinus thrombosis presenting as acute cerebral infarction and aneurysmal subarachnoid hemorrhage: Case report.

RATIONALE: Septic cavernous sinus thrombosis (SCST) is a rare infectious thrombophlebitic disease. The infection often arises from the tissues surrounding the cavernous sinus as well as the cavernous sinus drainage. Early symptoms of SCST include fever, headache, proptosis, ptosis, bulbar conjunctival edema, and limited eye movement. The complications include venous sinus thrombosis, intracerebral abscess, and subdural empyema. Aneurysmal subarachnoid hemorrhage combined with acute cerebral infarction has not been reported. PATIENT CONCERNS: A 46-year-old man presented with visual impairment in his right eye and intermittent headache for 2 months. Ten days later, the patient developed a sudden loss of consciousness, coma, cardiac arrest, and respiratory arrest. The patient eventually died. DIAGNOSES: SCST, acute cerebral infarction, aneurysmal subarachnoid hemorrhage, anterior cerebral artery aneurysm. INTERVENTIONS: Antiplatelet and lipid-lowering therapy, antibiotic treatment, emergency aneurysm clipping, and decompressive craniectomy. OUTCOMES: The patient underwent emergency aneurysm clipping and decompressive craniectomy, and postoperative head computed tomography showed a massive cerebral infarction in the right cerebral hemisphere. The patient eventually died. LESSONS: We report a case of SCST mainly presenting as acute cerebral infarction and aneurysmal subarachnoid hemorrhage, with an acute onset and ultimately a poor prognosis. This complication is extremely rare and have not yet reported according existing literatures but can be life-threatening if not recognized and treated promptly. Early antibiotic administration and early sinus drainage may alter the patient's prognosis. By describing this unusual the case we hope to raise awareness of the need of early illness detection and treatment in order to avoid catastrophic consequences. It also exemplifies the mechanism of acute inflammatory disorders and aneurysm development.

A case of Lemierre's syndrome causing panhypopituitarism, cavernous sinus thrombosis, ischaemic stroke and pulmonary embolism.

Infection is a rare cause of panhypopituitarism and has not been reported in the context of Lemierre's syndrome. We present the case of a previously well 19-year-old man, who presented acutely unwell with meningitis and sepsis. Fusobacterium necrophorum was isolated from peripheral blood cultures and identified on cerebrospinal fluid with 16S rDNA Polymerase Chain Reaction (PCR). Imaging demonstrated internal jugular vein thrombosis with subsequent cavernous venous sinus thrombosis. Pituitary function tests were suggestive of panhypopituitarism. The patient was diagnosed with Lemierre's syndrome complicated by meningitis, cavernous sinus thrombosis, base of skull osteomyelitis, ischaemic stroke and panhypopituitarism. He was treated with 13 weeks of intravenous antibiotics followed by 3 weeks of oral amoxicillin, and anticoagulated with dalteparin then apixaban. His panhypopituitarism was managed with hydrocortisone, levothyroxine and desmopressin.

Posterior Nasal Septal Abscess Detected During Evaluation of Cavernous Sinus Thrombosis.

Septic cavernous sinus thrombosis (CST) is a rare, life-threatening condition that commonly originates from sinusitis. Posterior nasal septal abscess (NSA) is an extremely rare cause of septic CST because it is a very rare condition by itself. Here we report a rare case involving an elderly woman with septic CST associated with a posterior NSA that was successfully treated without any sequelae. Incision and drainage of the posterior NSA were performed under local anesthesia, and the nasal packing was removed 2 days postoperatively. Pus from the abscess was sent for culture and sensitivity analyses, which revealed Enterococcus faecium . She was treated with intravenous (IV) third-generation cephalosporin (2 g twice daily) and IV vancomycin (0.75 g twice daily) for 4 weeks. IV low-molecular-weight heparin was administered at a dose of 40 mg twice daily for 4 days, followed by warfarin (3 mg once a day) for 21 days. The patient was discharged without any sequelae after 4 weeks. At the 2-month follow-up, she did not complain of any further symptoms. The findings from this case suggest that clinicians should maintain a high index of suspicion and provide prompt treatment to prevent mortality and morbidity associated with septic CST.

A rare case of cavernous sinus thrombosis following oral squamous cell carcinoma - The etiology and management dilemma.

Intracranial cavernous sinus metastases of oral squamous cell carcinoma (OSCC) are rare, with a reported incidence of 0.4 %. Due to their extremely infrequent presentation the etiology and management modalities of such complications are not clearly represented in the literature. Here we present a case of a 58-year-old male diagnosed with OSCC of Right Lower Alveolus with underlying bone invasion, cT4aN1M0, Stage IV. He underwent Right Hemi-mandibulectomy with Modified Neck Dissection, Pectoralis Major Myocutaneous Flap, and 60 Gy/30# adjuvant radiotherapy. Six months later, the patient was diagnosed with recurrence involving the right infratemporal fossa with associated right cavernous sinus thrombosis. Immunohistochemistry block review showed PDL1 - Positive. The patient was subjected to Cisplatin and Pembrolizumab immunotherapy. After receiving 35 cycles of Pembrolizumab over a period of 2 years the patient is doing well with no recurrence.

Cavernous sinus and jugular thromboses, base of skull osteomyelitis and cranial nerve palsies: catastrophic complications of sphenoid sinusitis.

Sphenoid sinusitis is a clinically important entity as it may be associated with catastrophic complications including cavernous sinus thrombosis (CST), cerebral abscess or infarction, meningitis, base of skull osteomyelitis and cranial nerve palsies. We report a case of occult sphenoid sinusitis presenting as Streptococcus intermedius bacteraemia, bilateral jugular vein and CST, cranial nerve palsy and base of skull osteomyelitis.

Cavernous sinus thrombosis with bilateral orbital vein involvement and diffuse ischemic retinopathy / Trombose do seio cavernoso com envolvimento bilateral das veias orbitais e retinopatia isquêmica difusa

ABSTRACT A 53-year-old man with a 3-day history of periorbital swelling and vision loss in the left eye was found to have septic cavernous sinus thrombosis with bilateral orbital vein involvement causing congestive orbitopathy. He was treated with an emergent canthotomy and cantholysis, intraocular pressure-lowering drops, antibiotics, anticoagulation, and serial examinations. Optical coherence tomography ultimately revealed diffuse ischemic destruction of both layers of the retina, which suggested occlusion of the ophthalmic artery or the short posterior ciliary arteries and central retinal artery without intracavernous internal carotid artery involvement. The patient remained without light perception in the left eye after treatment.

RESUMO Um homem de 53 anos, com história de 3 dias de edema periorbital e perda de visão no olho esquerdo, apresentou trombose séptica do seio cavernoso com envolvimento bilateral das veias orbitais, causando uma orbitopatia congestiva. O paciente foi tratado com uma cantotomia e cantólise de emergência, colírios para redução da pressão intraocular, antibióticos, anticoagulantes e exames seriados. A tomografia de coerência óptica finalmente demonstrou destruição isquêmica difusa de ambas as camadas da retina, sugerindo uma oclusão da artéria oftálmica ou das artérias ciliares posteriores curtas e da artéria retiniana central, com ausência de envolvimento do segmento intracavernoso da artéria carótida interna. O paciente permaneceu sem percepção luminosa no olho esquerdo.

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.

Bilateral Longus Colli Abscesses as a Complication of Advanced Bacterial Rhinosinusitis.

Known complications of acute bacterial rhinosinusitis include retropharyngeal abscess, cavernous sinus thrombosis, intracranial abscess, and associated sequelae. We describe the case of a patient with longus colli abscess formation resulting from acute pansinusitis, complicated by bilateral cavernous sinus thrombosis in the setting of concurrent viral pneumonitis, severe sepsis, and a large area cerebral infarction. The bilateral longus colli abscesses were drained via stereotactic image-guided endonasal sinus surgery, yielding Staphylococcus hominis in culture. The described disease progressed rapidly over a 2-week course amid the COVID-19 pandemic.

Cavernous sinus thrombosis with bilateral orbital vein involvement and diffuse ischemic retinopathy.

A 53-year-old man with a 3-day history of periorbital swelling and vision loss in the left eye was found to have septic cavernous sinus thrombosis with bilateral orbital vein involvement causing congestive orbitopathy. He was treated with an emergent canthotomy and cantholysis, intraocular pressure-lowering drops, antibiotics, anticoagulation, and serial examinations. Optical coherence tomography ultimately revealed diffuse ischemic destruction of both layers of the retina, which suggested occlusion of the ophthalmic artery or the short posterior ciliary arteries and central retinal artery without intracavernous internal carotid artery involvement. The patient remained without light perception in the left eye after treatment.

Orbital cellulitis and cavernous sinus thrombosis with contralateral sinus disease in a COVID-19 positive adolescent patient.

Patients with COVID-19 have been reported to have elevated coagulation factors, which is a well-documented cause of venous thromboembolism events such as deep vein thrombosis and pulmonary embolism. Other venous thrombotic events, however, such as cavernous sinus thrombosis (CST) have been less commonly observed, specifically in combination with primary orbital cellulitis. Due to its unique anatomic location, the cavernous sinus is susceptible to thrombophlebitis processes including septic thrombosis and thrombosis most commonly from sinusitis. Many studies have shown that in the antibiotic era thromboembolic events of the cavernous sinus are less common due to infection spread from the orbit or facial region. This case report describes a 17-year-old COVID-19 positive male who presented with a left-sided primary orbital cellulitis with CST without radiographic evidence of ipsilateral sinus disease.

Superior ophthalmic vein and cavernous sinus thrombosis associated with COVID-19: a case report / Trombose de veia oftálmica superior e seio cavernoso associada à COVID-19: relato de caso

ABSTRACT Cavernous sinus and superior ophthalmic vein thrombosis is a rare clinical condition, and little described in the literature. The clinical presentation is nonspecific and highly variable, and symptoms may include red eye, ophthalmoplegia, coma, and death. The main etiology results from infection of the paranasal sinuses. The final diagnosis must be made through imaging tests such as magnetic resonance imaging. We describe a case of cavernous sinus and superior ophthalmic vein thrombosis after COVID-19 infection in a 64-year-old patient with persistent ocular hyperemia and pain on eye movement. Ophthalmological examination showed preserved visual acuity, conjunctival hyperemia, dilation of episcleral vessels and retinal vascular tortuosity in the right eye. Magnetic resonance imaging confirmed the diagnosis. The association with the COVID-19 was raised, excluding other infectious causes. Enoxaparin and Warfarin were started with significant improvement in the ocular clinical presentation and maintenance of initial visual acuity after 12 months of follow-up.

RESUMO A trombose de seio cavernoso e veia oftálmica superior é uma condição clínica rara e pouco descrita na literatura. A apresentação clínica é inespecífica e altamente variável. Os sintomas podem incluir olho vermelho, oftalmoplegia, coma e morte. A etiologia principal resulta da infecção dos seios paranasais. O diagnóstico final deve ser efetuado por meio de exames de imagem, como ressonância magnética. Descrevemos um caso de trombose de seio cavernoso e veia oftálmica superior após COVID-19 em paciente de 64 anos e com quadro de hiperemia ocular persistente e dor à movimentação ocular. Ao exame oftalmológico, observou-se acuidade visual preservada, hiperemia conjuntival, dilatação de vasos episclerais e tortuosidade vascular retiniana em olho direito. A ressonância confirmou o diagnóstico. A associação com a COVID-19 foi levantada, excluindo-se demais causas infecciosas. Prescrevemos enoxaparina e varfarina, com melhora do quadro clínico ocular e manutenção da acuidade visual inicial após 12 meses de acompanhamento.

Tratamiento con bloqueo esfenopalatino de la cefalea refractaria por trombosis del seno cavernoso / Treatment with sphenopalatine blockade against refractory headache due to thrombosis of the cavernous sinus

Introducción: Entre las cefaleas secundarias se encuentra la atribuida a flebotrombosis cerebral producida por trombosis séptica del seno cavernoso. El ganglio esfenopalatino interviene en la génesis y mantenimiento de cefaleas unilaterales; pues envía conexiones a la cavidad nasofaríngea y meninges, así desempeña una función importante en la modulación neuronal; el bloqueo de dicho ganglio es un método fácil, seguro, económico y efectivo de tratamiento del dolor irruptivo de algunos tipos de cefalea. Objetivo: Presentar los resultados del bloqueo GEFP en el tratamiento de la cefalea grave refractaria secundaria a trombosis séptica del seno cavernoso. Presentación de caso: Paciente de 71 años de edad, al que se realizó de forma exitosa bloqueo transnasal del ganglio esfenopalatino, para tratamiento de cefalea grave refractaria secundaria a trombosis séptica del seno cavernoso, consiguiéndose analgesia efectiva con disminución progresiva de la cefalea y control total de la misma a las 72 h de tratamiento. Conclusiones: El bloqueo podría constituir una opción en la terapéutica de este tipo de cefalea(AU)

Introduction: Among secondary headaches, one is attributed to cerebral phlebothrombosis produced by septic thrombosis of the cavernous sinus. The sphenopalatine ganglion (SPG) is involved in the genesis and maintenance of unilateral headaches, since it sends connections to the nasopharyngeal cavity and meninges, playing thus an important role in neuronal modulation; therefore; the blockade of this ganglion is an easy, safe, economic and effective method for treating breakthrough pain in some types of headache. Objective: To present the results of SPG blockade in the treatment of refractory severe headache produced by septic thrombosis of the cavernous sinus. Case presentation: A 71-year-old male patient is presented, who was successfully performed a transnasal SPG blockade, as a treatment for refractory severe headache caused by septic thrombosis of the cavernous sinus. Effective analgesia is achieved, together with progressive decrease of headache until it was totally controlled at 72 hours. Conclusions: Blockade was an option in the therapy of this type of headache(AU)