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.

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.

Cavernous Sinus Thrombosis and Blindness After Simple Tooth Extraction in Patient Who Recovered From Coronavirus 2019: A Case Report.

The pandemic Coronavirus 2019 is a disease transmitted either by droplets from a person's sneeze or cough or direct spread; also known as severe acute respiratory syndrome coronavirus-2. Although the morbidity of the disease is mainly related to respiratory distress, the associated inflammatory response can induce various coagulopathies despite an anticoagulant therapy. The authors are documenting a case of a diabetic patient who recovered from Coronavirus 2019 and is on prophylactic anticoagulant therapy after routine extraction of a maxillary second molar that progressed to unilateral cavernous sinus thrombosis and loss of vision.

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.

Double ophthalmic arteries arising from the internal carotid artery: a case report of a hidden second ophthalmic artery.

A case of double ophthalmic arteries arising from the internal carotid artery with unique features is reported. This case was discovered following in the course of time the progress of a thrombosis of the anterior cavernous sinus associated with a low-flow direct arteriovenous fistula of the superior ophthalmic vein. At different time points, the same patient underwent four angiographic studies and one computerized tomography with contrast medium. Angiographies showed that the double internal carotid artery origin of the ophthalmic artery was detectable only within a short range of time. To the best of our knowledge, this case is unique as it demonstrates that a second ophthalmic artery may lie hidden, showing itself only under particular hemodynamic requirements.

Cavernous sinus thrombosis: current therapy.

Cavernous sinus thrombosis represents a rare but devastating disease process that may be associated with significant long-term patient morbidity or mortality. The prompt recognition and management of this problem is critical. However, most of the literature involves case-specific discussions. The purpose of this article was to review the literature and present current recommendations for the treatment of cavernous sinus thrombosis.

Clinical Profile and Long-Term Outcomes in Pediatric Cavernous Sinus Thrombosis.

BACKGROUND: Pediatric cavernous sinus thrombosis (CST) is a rare condition with limited data regarding its clinical characteristics and long-term outcomes. The objective of this study was to describe the clinical and radiologic features, diagnostic evaluation, management, and long-term prognosis and to identify clinical variables associated with long-term outcomes in pediatric CST. METHODS: A retrospective chart review of patients younger than 18 years diagnosed with a CST between 2004 and 2018 at a single center was conducted. RESULTS: We identified 16 (M:F = 10:6) children with CST with a mean age of 7.6 years (10 days to 15 years) and average follow-up duration of 29 months (3 weeks to 144 months). The most common symptom and examination finding at presentation was eyelid swelling (n = 8). Six patients had bilateral CST. The most common etiologies were sinusitis (n = 5) and orbital cellulitis (n = 5). Treatments included antibiotics (n = 14), anticoagulation (n = 11), and surgery (n = 5). Only one patient died due to intracranial complications. Twelve patients had a normal examination at follow-up. None of the clinical variables including age (P = 0.14), gender (P = 0.09), use of antibiotics (P = 1.00) or anticoagulation (P = 1.00), surgery (P = 0.28), parenchymal abnormalities (P = 0.30), additional cerebral venous thrombosis (P = 0.28), and early versus late commencing of anticoagulation (P = 1.00) were significant when comparing patients with full/partial resolution versus those with no resolution of thrombosis on follow-up neuroimaging. CONCLUSIONS: Our study is one of the largest cohorts with the longest follow-up data for the pediatric CST. Most of our patients had favorable outcomes at follow-up. We found no statistical difference between clinical variables when comparing patients with full/partial resolution versus those with no resolution of thrombosis on follow-up neuroimaging.

Cavernous sinus thrombosis followed by brain ischaemia in a type-1 diabetic patient: a persistent endodontic infection report.

Central nervous system infections and cavernous sinus thrombosis are associated with high mortality rates and may be a consequence of oral infection propagation. A 24-year-old woman has attended a private dental office with a pain complaint in the upper right central incisor and had the endodontic treatment completed. However, the patient returned to the dental office reporting pain in the same tooth and the presence of swelling. Then, the root canal was retreated. After one week, the patient presented to a Basic Health Unit with a history of vomiting and convulsion crisis followed by loss of consciousness. A computed tomography exam showed cavernous sinus thrombosis and brain ischaemic areas. The present report describes a rare case of cavernous sinus thrombosis followed by brain ischaemia in a type-1 diabetic patient, associated with persistent endodontic infection, with subsequent patient's death.

Septic cavernous sinus thrombosis after minor head trauma: A case report.

RATIONALE: Septic cavernous sinus thrombosis (SCST) is a rare but life-threatening condition that commonly arises from infections, including paranasal sinusitis, otitis media, and skin infection. Meanwhile, head trauma as a predisposing factor of SCST has been scarcely reported. We report a case of SCST complicated by meningitis after minor head trauma, even in the absence of identifiable fractures. PATIENT CONCERNS AND DIAGNOSIS: A 77-year-old female presented with diplopia combined with ocular pain and headache lasting a week. She had a recent blunt head trauma 2 weeks before the diplopia onset. The trauma was not accompanied by identifiable skull fractures, bleeding, or loss of consciousness. Neurological examination revealed incomplete ptosis, eyelid swelling, and medial and vertical gaze limitations of both eyes. Gadolinium-enhanced brain magnetic resonance imaging demonstrated multifocal thrombotic filling defects, including those of the cavernous sinus, sinusitis involving the sphenoid and ethmoid sinuses, and otomastoiditis. The cerebrospinal fluid assay result was compatible with bacterial meningitis. A tentative diagnosis of SCST complicated by bacterial meningitis and multifocal cerebral venous thrombosis was made based on clinical, laboratory, and neuroradiologic findings. INTERVENTION: Intravenous triple antibiotic therapy (vancomycin, ceftriaxone, and ampicillin) for 2 weeks combined with methylprednisolone (1 g/d for 5 days) was administered. Despite the initial treatment, carotid-cavernous fistula was newly developed during hospitalization. Therefore, coil embolization was performed successfully for the treatment of carotid-cavernous fistula. OUTCOMES: The symptoms of the patient including diplopia gradually improved during the 8-month follow-up period. LESSONS: Minor head trauma is a rare but possible cause of SCST. Early recognition and prompt treatment are essential for improving outcomes. Moreover, close observation is warranted, even if apparent serious complications were absent during initial evaluations in minor head trauma.

Septic cavernous sinus thrombosis: A review.

Septic cavernous sinus thrombosis (SCST) is a rare, yet severe, process typically arising from infections of the paranasal sinuses (predominately ethmoid and/or sphenoid sinusitis) and less commonly, otogenic, odontogenic, and pharyngeal sources. Clinical symptoms of SCST arise from obstruction of venous drainage from the orbit and compression of the cranial nerves within the cavernous sinus. In the preantibiotic era SCST was considered universally fatal (80-100%); however, with the introduction of antibiotics the overall incidence, morbidity, and mortality of SCST have greatly declined. In spite of dramatic improvements, morbidity and mortality remain high, with the majority of patients experiencing neurological sequalae, highlighting the severity of the disease and the need for prompt recognition, diagnosis, and treatment. Here we review of the literature on SCST with a focus on the current recommendations and recent evidence for diagnostic and medical management of this condition.

Alternating orbital symptoms in cavernous sinus syndrome due to isolated sphenoid sinusitis.

A 40-year-old male with left-sided headaches, ptosis, proptosis and extra-ocular muscle paralysis developed right-sided headaches, proptosis, chemosis, diplopia, extra-ocular muscle paralysis and trigeminal sensory loss. An enhancing left orbital, intrasellar and parasellar cavernous nodule on magnetic resonance imaging progressed into a right cavernous sinus and orbital apex soft tissue mass. Cavernous sinus syndrome from sphenoid sinusitis resolved after endoscopic transnasal sphenoidotomy. This diagnostic complexity and its treatment options are discussed according to current literature.

Coil embolization of cavernous sinus in patients with direct and dural arteriovenous fistula.

To determine technical success and acute complication rates after endovascular coil packing of the cavernous sinus. Nineteen patients presented with either direct (13) or dural (6) arteriovenous fistula (AVF) and were treated by means of coil embolization of the cavernous sinus. The aim of treatment was complete obliteration of the fistula. In a retrospective study, the degree of obliteration, regression of symptoms as well as complication rates were evaluated. Initial complete obliteration was achieved in 12 patients, subtotal occlusion of the sinus in 6 and incomplete packing with major residual fistula in 1 of the patients. Retreatment was successfully performed in two patients with early recurrence of AVF. Follow-up showed complete occlusion rates in 16 and subtotal obliteration in 3 patients. Chemosis and exophthalmus regressed rapidly in all affected patients. Persistence of cranial nerve deficits was observed in 11 cases. Postinterventional thrombosis of the ophthalmic vein was the only major acute complication (n = 2). Coil embolization of the cavernous sinus in cases with AVF is a complex procedure that is technically feasible and safe in the majority of cases. Adequate anticoagulation is recommended to avoid thrombembolic complications. Long-term outcome has to be determined by further studies.

Preoperative and postoperative intracranial complications of acute mastoiditis.

OBJECTIVES: We determined the clinical characteristics and treatment outcomes of an unusual cluster of intracranial complications seen in acute mastoiditis (AM). METHODS: We performed a retrospective review of pediatric patients treated for AM in a tertiary care hospital from March 2006 to March 2007. RESULTS: Eleven children, 6 months to 10 years of age (mean age, 3.8 years), were treated for AM confirmed by computed tomography, which identified asymptomatic intracranial complications in 8 of the 11 patients: these were sigmoid sinus thrombosis (4 patients), epidural abscess (4), perisigmoid abscess or bony erosion (2), and tegmen mastoideum dehiscence (1). All patients required operative intervention with tympanomastoidectomy, although only 2 patients required neurosurgical intervention, consisting of evacuation of epidural abscess and sigmoid sinus thrombosis, respectively. Cultures yielded routine organisms and 1 multidrug-resistant strain of Streptococcus pneumoniae. One patient developed reaccumulation of the subperiosteal abscess that required revision mastoidectomy, and another patient developed postoperative sigmoid sinus thrombosis. CONCLUSIONS: Although uncommon, intracranial complications of AM may present without clinical signs or symptoms. Computed tomography of the temporal bone with contrast is essential for identifying asymptomatic complications. Mastoidectomy remains the mainstay of surgical treatment. Neurosurgical intervention and anticoagulation may be avoided with protracted postoperative intravenous antibiotics. Postoperative vigilance is crucial, as complications may evolve despite aggressive therapy.

Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus.

PURPOSE: Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus. METHODS: A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus. RESULTS: The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms. CONCLUSION: A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.

Cavernous sinus thrombosis secondary to allergic fungal sinusitis.

Cavernous sinus thrombosis (CST) is a rare and serious complication secondary to invasive fungal sinusitis, but rarer still in cases of allergic fungal sinusitis. Current recommendations for cavernous sinus thrombosis are controversial, especially regarding anticoagulation, secondary to the rarity of the diagnosis. Early surgical debridement and intravenous antibiotics are crucial to prevent mortality and decrease morbidity. Because thrombosis is thought to be caused by a bacterial superinfection, which follows a response to Aspergillus, antifungals may not be necessary. Despite the controversy, most physicians opt to treat with anticoagulation.

Diagnosis and Management of Cerebral Venous Diseases in Neuro-Ophthalmology: Ongoing Controversies.

Diseases of the cerebral venous system frequently lead to neuro-ophthalmic complications. Cortical venous sinus thrombosis and dural arteriovenous fistulas may be complicated by elevation of intracranial pressure, with secondary papilledema or abducens palsies. There is increasing recognition that stenosis at the transverse sinus-sigmoid sinus junction plays a role in the pathophysiology of idiopathic intracranial hypertension and offers a new avenue of treatment in patients who fail medical therapy. Diseases of the cavernous sinus manifest with their own set of neuro-ophthalmic symptoms, reflecting the presence of all 3 ocular motor nerves and the oculosympathetic fibers within its walls, along with its role as the primary drainage pool of the globe and orbit. Numerous questions and controversies remain regarding the diagnosis and optimal treatment of cerebral venous disease, including the role of venous stenting in idiopathic intracranial hypertension, the role of anticoagulation in cavernous sinus thrombosis, and the risks and benefits of embolization of mild indirect cavernous carotid fistulas.

Septic cavernous sinus thrombosis in a paediatric patient with undiagnosed thrombophilia.

A previously healthy 8-year-old girl presented to the hospital with right periorbital and forehead swelling in the setting of a 1-week history of upper respiratory symptoms. Contrast-enhanced CT revealed pansinusitis with orbital and frontal abscesses and thrombosis of the anterior portion of the superior sagittal sinus. She was treated with surgical drainage, antibiotics and anticoagulants. After 2 days she developed cranial nerve (CN) VI palsy. Contrast-enhanced MRI revealed small epidural abscess, right-sided thrombi of the cavernous sinus, internal carotid artery and internal jugular vein, in addition to the superior sagittal sinus. Thrombophilia workup revealed heterozygosity for factor V Leiden. She underwent 6 weeks of parental antibiotic therapy, 3 months of anticoagulation therapy and 7 days of steroids. With treatment, her visual acuity returned to baseline, CN VI palsy resolved and repeat imaging showed resolution of thrombi and epidural abscess, but persistent narrowing of the internal carotid artery.

Cavernous sinus thrombosis and meningitis from community-acquired methicillin-resistant Staphylococcus aureus infection.

Septic cavernous sinus thrombosis is an uncommon clinical syndrome with a high morbidity and mortality. The commonest bacterial pathogen is Staphylococcus aureus. We describe the study of a patient with cavernous sinus thrombosis and meningitis caused by community-acquired methicillin-resistant S. aureus (CA-MRSA) infection. The isolate was genotyped as the ST93 (Queensland) clone of CA-MRSA and carried the Panton-Valentine leucocidin genes. Cure was obtained following prolonged antimicrobial therapy with vancomycin, rifampicin, cotrimoxazole and linezolid. Given the high morbidity and mortality of cavernous sinus thrombosis and the worldwide recent emergence of CA-MRSA, clinicians treating patients with this infection should consider early empirical coverage for CA-MRSA with an antimicrobial agent, such as vancomycin or linezolid, particularly in the presence of suspected facial staphylococcal skin infections. If vancomycin is used, we emphasize that high doses may be required to achieve even low levels in the cerebrospinal fluid.

Bilateral intraorbital abscesses and cavernous sinus thromboses secondary to Streptococcus milleri with a favorable outcome.

A 51-year-old woman with left proptosis, diplopia, headache, and nausea was found to have bilateral intraorbital abscesses, left superior ophthalmic vein thrombosis, bilateral cavernous sinus thromboses, and a left temporal lobe intracerebral abscess. Because the paranasal sinuses were unaffected, a dental origin was suspected and confirmed. The causative organism was Streptococcus milleri. Aggressive surgical intervention included bilateral orbital abscess drainage and dental extraction, and medical therapy included intravenous metronidazole, ceftriaxone, heparin, and methylprednisolone. A left sixth cranial nerve paresis was the only long-term sequela.