The association between otogenic lateral sinus thrombosis and thrombophilia - A long-term follow-up.

PURPOSE: Otogenic lateral sinus thrombosis (OLST) is an intracranial, potentially life-threatening complication of acute and chronic otitis media. Since congenital thrombophilic disorders are risk factors for cerebral venous thrombosis, OLST may be related to thrombophilia. The aim of our study was twofold: to evaluate whether patients who suffered from OLST in childhood also have thrombophilia, and whether these patients experienced thromboembolic episodes in future years. STUDY DESIGN: Retrospective case series. METHODS: The medical charts of all children hospitalized for OLST at Soroka University Medical Center of Israel, a tertiary referral hospital, from January 1983 to September 2014 were reviewed. The patients were invited for a follow-up visit and comprehensive medical history was taken along with a physical examination and laboratory work-up for thrombophilia. MAIN FINDINGS: Seven patients were included in the study. Of these, 3 (43%) had results suggesting thrombophilic disorders manifested by elevated levels of factor IX and decreased levels of protein S activity (n = 1), decreased levels of proteins C and S activity (n = 1), and elevated levels of antibodies to cardiolipin (n = 1). No patients experienced clear thrombophilic events; however, 2 patients (29%) with later proven thrombophilia suffered neurologic sequelae, possibly suggesting thrombophilic events. CONCLUSIONS: Pediatric OLST secondary to acute otitis media and mastoiditis may reflect an underlying thrombophilia. Laboratory work-up for thrombophilia should be performed, and anticoagulant treatment may be warranted in managing these patients.

Safety of Superior Petrosal Vein Sacrifice During Microvascular Decompression of the Trigeminal Nerve.

BACKGROUND: Microvascular decompression (MVD) is a safe and effective treatment for trigeminal neuralgia. Cerebellar venous infarction is a complication associated with surgical sacrifice of the superior petrosal vein (SPV). The SPV intervenes between the trigeminal nerve and the surgeon. Optimal exposure of the cisternal trigeminal nerve, particularly at the brainstem, can be achieved by sacrificing the SPV. We analyzed a cohort of 224 patients to determine the frequency of cerebellar venous infarction. METHODS: Retrospective analysis of records and neuroradiology for patients undergoing trigeminal MVD at the Manchester Skull Base Unit between August 1st 2008 and July 31st 2015. RESULTS: A total of 184 of 224 (82%) patients had coagulation and division of the main stem of the SPV. There were no cases of venous infarction. There was one case of mild, transient, cerebellar symptoms and signs, with no radiologic evidence of venous infarction. This patient had SPV sacrifice at surgery but also had postoperative thrombosis of the transverse sinus. Venous sinus thrombosis affected 5 of 184 (2.7%) patients. A total of 208 of 224 (93%) patients had a good outcome with improvement or resolution of their trigeminal neuralgia at 3 months. CONCLUSIONS: The overall rate of venous complications in this study was 2.7%; however, we had no cases of venous infarction in 184 patients who had sacrifice of the SPV. The incidence of venous infarction associated with SPV obliteration during MVD surgery is therefore <0.5%. SPV sacrifice may be used where necessary to optimize visualization of the root entry zone and maximize the chance of effective decompression of the trigeminal nerve.

Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation.

BACKGROUND: The role of intracardiac echocardiography (ICE) to detect thrombus within left atrium (LA) before atrial fibrillation (AF) ablation despite a recent transesophageal echocardiogram (TEE) is not well defined. We examined the prevalence of LA/left atrial appendage (LAA) thrombus using ICE immediately prior to AF ablation in patients in whom anticoagulation was not withheld. METHODS: We analyzed 122 consecutive patients (62.6 ± 10.8 years, 90 males, CHA(2)DS(2) -VASc score 2.4 ± 1.5, persistent AF 29.5 %) who underwent an ICE-guided AF ablation 1 day after a negative (n = 120) or inconclusive (n = 2) TEE for LA thrombus. LA was imaged with ICE from the right atrium, coronary sinus, and right ventricular inflow tract (RVIT). ICE and TEE images were compared for LAA area, thrombus, and spontaneous echo contrast (SEC). RESULTS: LAA was adequately visualized in 99 and 100 % of patients with TEE and ICE, respectively. RVIT was the best ICE view for LAA visualization. The LAA 2-D-area measured by TEE was 4.9 ± 0.5 vs. 5 ± 0.5 cm(2) by ICE (P = NS). ICE identified a thrombus in seven patients with a previous negative TEE, leading to cancellation of ablation. It ruled out a thrombus in two patients with an inconclusive TEE. Thrombi were found in the LAA (n = 4), atrial septum (n = 2), and left superior pulmonary vein (n = 1). SEC during TEE was more frequent in patients with thrombus on ICE than those without (85.7 vs. 17.4 %; p = 0.03; positive predictive value 23.1 %, negative predictive value 98.9 %). CONCLUSIONS: The results of our staged imaging approach suggest that ICE has a complimentary value in re-screening the LA/LAA for thrombus after a recent negative or equivocal TEE. The presence of SEC during TEE increases the probability of finding a thrombus with ICE, which could potentially be dislodged during catheter manipulation.

Isolated lateral sinus thrombosis: a series of 62 patients.

BACKGROUND AND PURPOSE: Isolated lateral sinus thrombosis was long considered a complication of middle ear disease. Little attention has been recently paid to this variety of thrombosis. We therefore reviewed all cases of isolated lateral sinus thrombosis prospectively collected in our center (1997 to 2006). METHODS: Among 195 patients with cerebral venous thrombosis (CVT), we identified 157 patients with lateral sinus thrombosis, including 62 patients with isolated lateral sinus thrombosis. Clinical, etiologic, and prognostic features were compared with those of other 133 CVT cases. RESULT: Sixty-two patients (32%) had isolated lateral sinus thrombosis. Headaches were present in 95% of patients. The main clinical presentation was isolated headache in 28 patients (45%), whereas 15 (24%) had isolated intracranial hypertension. Nineteen patients (31%) had at least one focal sign (deficit and/or focal seizure). Dysphasia was the most common one (8 patients). Compared with the other 133 CVT cases, presentation with isolated headaches was the most frequent one (P<0.001). Parenchymal lesions were found in 19 cases and were less frequent than in other CVT cases (P=0.007). Numerous causes or predisposing factors were identified without a difference in repartition with other patients with CVT, particularly for local or infectious causes. Treatment consisted of anticoagulation in all patients. Clinical outcome was good with complete recovery in 57 patients (92%). One patient died after the occurrence of massive pulmonary emboli despite adequate anticoagulation. Three patients had sequelae (no difference with the other CVT). CONCLUSIONS: Isolated lateral sinus thrombosis is a frequent variety of CVT, accounting for one third of all CVT. It presents in more than two thirds of cases with headache as the only symptom either isolated or less frequently associated with papilledema. This stresses the need for CVT workup in a patient with a recent unexplained headache.

Lateral sinus thrombosis: complication of minor head injury.

OBJECTIVE: Our review aims: (1) to highlight the suspicion of lateral sinus thrombosis (LST) following a minor head injury in the pediatric population; (2) to discuss the different etiologies of lateral sinus thrombosis; (3) to identify an exact mechanism of the thrombus formation; (4) to clarify the role of each diagnostic tool; (5) to implement an algorithm for the treatment of LST due to a minor head injury. METHOD: We performed a MEDLINE search for LST following a minor head trauma related articles that were published between 1950 and June 2008. We identified 19 related studies of which 22 patient records were noted. We also added our case to this series. The information from the reports was analyzed to characterize the clinical aspects, the radiologic findings, the treatment, the follow-up, and the management of this disease. RESULTS: Twenty-three cases (20 pediatrics and 3 adults) of LST following a minor head trauma have been published including the new one presented here. The mean pediatric age in this series is 7.8 years. There were 11 cases on the right side and 8 on the left side. Male to female ratio is 1.4:1. Side and sex were not reported in 4 and 6 cases, respectively. Sigmoid and transverse sinuses were the most affected one. Eighty-three percent were treated by observation while the remaining 17% received anticoagulation. The outcome was good in all patients without any notable major complications. The radiological investigation showed that there was a complete recanalization in 9 patients and a partial recanalization in 3 patients with a mean time of 8.3 weeks. CONCLUSION: Lateral sinus thrombosis seldomly occurs following a minor head injury. This entity is difficult to diagnose and one should exercise a high degree of suspicion when confronted with an ambiguous neurological status following a closed head trauma. The most accurate imaging test according to our experience is a multiple detector row computerized tomography (MDCT) venography completed at the time of the presentation. The indication to proceed with an MRI has to be assessed on a case-by-case basis. Anticoagulation is reserved for patients presenting a papilledema or for patients complaining of persistent headaches, vomiting, or disequilibrium.

Canal-down mastoidectomy: experience in 81 cases.

OBJECTIVES: To identify the common presentation(s) and the clinical and operative finding(s) in patients with cholesteatomatous and long-term noncholesteatomatous chronic suppurative otitis media and to adapt a surgical management best suited to ensure long-term safety in these Papua New Guinean patients for whom postoperative follow-up is minimal. DESIGN: Retrospective case series. SETTING: Port Moresby General Hospital, the tertiary referral center for otolaryngologic services. PATIENTS: Eighty-one patients in all age groups who received a clinical diagnosis of chronic suppurative otitis media, with or without cholesteatoma, with or without its associated complications. INTERVENTION: Canal-down (modified radical) mastoidectomy with wide meatoplasty. MAIN OUTCOME MEASURE AND RESULTS: Adults were more commonly affected than adolescent or pediatric cases, and there was a male preponderance. The median age was 24 years (range, 13 months to 73 years). Otorrhea remained the most common presentation in all age groups. Postauricular abscesses and fistulae were seen frequently. Cholesteatoma and granulation with polypoidal mucosa were frequent operative findings; a high incidence involved both the attic space and the antrum. Five (6%) patients had preoperative facial paralysis; in addition, postoperative facial paralysis developed in three (4%) patients. The incidence of postoperative "wet ear" was high in all age groups. Meningitis was the most common intracranial complication, followed by lateral sinus thrombosis. There were seven (9%) deaths altogether, and all the deaths occurred as a direct result of otogenic intracranial complication. CONCLUSION: Lack of health consciousness, poor socioeconomic status, and lack of health care delivery system resulted in late presentations and poor postoperative follow-up. Hence, the canal-wall-down technique with wide meatoplasty is recommended to ensure a best possible one-time treatment in Papua New Guinean patients with cholesteatomatous or long-term "dangerous" chronic suppurative otitis media with or without complications.

A unique case of Bezold's abscess associated with multiple dural sinus thromboses.

OBJECTIVES/HYPOTHESIS: Bezold's abscess and dural sinus thromboses are rare complications of otitis media in the era of antibiotics. Although potentially fatal, they are treatable. We present a unique case report of Bezold's abscess in association with multiple dural sinus thromboses. STUDY DESIGN: Single case report. METHODS: A young female patient's clinical course is presented and discussed. We review the anatomy, incidence, pathogenesis, and treatment of Bezold's abscess and dural sinus thrombosis. RESULTS: After mastoidectomy, neck exploration, broad-spectrum intravenous antibiotics, and anticoagulation therapy, the patient recovered fully and has remained asymptomatic since her discharge from the hospital at 12 months' follow-up. CONCLUSIONS: This is the first reported case of Bezold's abscess associated with a cavernous sinus thrombosis and the third reported case of Bezold's abscess associated with lateral sinus thrombosis. Despite its rarity, Bezold's abscess must be recognized and treated aggressively. Dural sinus thrombosis is relatively more common, and treatment of the underlying cause is essential. The diagnosis and rapid, aggressive treatment of these conditions are essential for an optimal clinical outcome.