Septic Cavernous Sinus Thrombosis Research Articles

Septic Cavernous Sinus Thrombosis: Clinical Characteristics, Management, and Outcomes.

Septic cavernous sinus thrombosis (CST) is a rare condition traditionally associated with high morbidity and mortality. More recent case series report more favorable outcomes, including full functional recovery. A comprehensive assessment of the clinical characteristics and prognostic factors of visual and survival outcomes in septic CST is warranted to contemporize current understanding and help guide management. A multicentered retrospective cohort study was conducted at 2 tertiary care centers using an electronic medical record search of the term, "thrombosis of cavernous venous sinus" between January 1, 2000, and December 31, 2021. Inclusion criteria consisted of active infection and radiographic evidence of associated CST. Demographic and clinical data extracted included age at presentation, sex, infection type and extent, and ophthalmic examination findings at presentation-best-corrected visual acuity (BCVA), presence of relative afferent pupillary defect (RAPD), intraocular pressure (IOP), and extraocular motility (EOM) limitation. Management data collected consisted of type and length of antimicrobial therapy, type and length of anticoagulation administration, and surgical intervention. Primary outcomes assessed were ophthalmic examination findings at final evaluation and same-hospitalization mortality. A total of 27 patients with imaging-confirmed septic CST were identified at 2 tertiary care centers. At presentation, 2 (8.7%) patients had no light perception (NLP) vision, 8 (29.6%) patients had RAPD, 17 (73.9%) patients had EOM limitation, and 13 (54.2%) had IOP >21 mm Hg. All patients received antimicrobial therapy, with vancomycin being the most common agent. Fifteen patients (55.6%) received anticoagulation, and 21 (81.5%) patients underwent surgical intervention. Same-hospitalization mortality was 3 (11.1%). Among the 21 patients with ophthalmic data at follow-up, 3 (16.7%) had NLP vision, 5 (23.8%) had a persistent RAPD, 7 (31.8%) had persistent EOM limitation, and no patients had IOP elevated above 21 mm Hg. Patients with RAPD at presentation had significantly worse BCVA at final evaluation (logMAR BCVA 1.43 higher on average, P = 0.01) and a significantly higher mortality rate (37.5% vs. 0.0%, P < 0.01) than non-RAPD patients. Demographic features, BCVA at presentation, EOM limitation at presentation, elevated IOP at presentation, and comorbid orbital cellulitis were not associated with worse visual or mortality outcomes. Septic CST may result in permanent ophthalmic functional deficit in almost one-third of cases and mortality in approximately 11% of patients under contemporary management. New RAPD at presentation may indicate higher risk of poor visual and survival outcomes.

Lemierre syndrome associated Cavernous Sinus Thrombosis and Development of Internal Carotid Artery Narrowing: A Case Report and Review of Literature (P2-5.005)

<h3>Objective:</h3> To report a case of Lemierre syndrome complicated by cavernous sinus thrombosis (CST) and bilateral internal carotid artery (ICA) stenosis without cerebral infarction in a young woman and summarize the literature on Lemierre syndrome with arterial involvement. <h3>Background:</h3> Lemierre syndrome is a complication of oropharyngeal infection characterized by thrombosis of the internal jugular vein (IJV) with septic thrombophlebitis followed by bacteremia and septic emboli dissemination to distal organs, but arterial involvement is extremely rare. <h3>Design/Methods:</h3> A 24-year-old previously healthy woman presented to the hospital with one week of progressive jaw pain and neck swelling after recent tooth extraction. Physical examination showed left ptosis without other neurologic deficits. Computer tomography (CT) of the neck found multiple anterior neck abscesses. The patient underwent emergent incision and drainage of abscess at the left lateral pharyngeal, left masticator, and bilateral sublingual space. Vascular imaging revealed findings of non-occlusive thrombus in the left IJV, bilateral cavernous sinus thrombosis (CST), and septic emboli in bilateral apical lungs, consistent with Lemierre syndrome. Neuroimaging showed no cerebral infarction even though a digital subtraction angiogram (DSA) demonstrated bilateral ICA severe stenosis (&gt;70%) in both extracranial and intracranial segments. Cultures of abscess samples proved positive for <i>Candida albicans</i> and <i>Streptococcus constellatus</i>. The patient received treatment with full-coverage antibiotics and anticoagulation therapy resulting in an excellent outcome. <h3>Results:</h3> A literature search yielded 29 cases of Lemierre syndrome with arterial complications, which manifested as ICA occlusion or stenosis, or mycotic aneurysm development. Despite variable clinical symptoms, most patients developed CST and were all treated with antibiotics. Anticoagulation therapy is controversial given scarce and inconsistent evidence. <h3>Conclusions:</h3> The presented case and literature review emphasize the variability of the clinical course of Lemierre syndrome. Septic CST can be a rare cause of ICA occlusion, stenosis, or pseudoaneurysms because of arteritis, and thus expedited workup is necessary. <b>Disclosure:</b> Dr. Zhou has nothing to disclose. Dr. Malik has nothing to disclose.

Hypercoagulability and Cavernous Sinus Thrombosis due to Protein C Deficiency. A Case Report

Background: Thrombophilia due to Protein C deficiency is a rare condition, present in 0.2% of general population. Cerebral venous thrombosis has an incidence of 3-4 cases per million in adults. A combination of both is very uncommon. Patients with these conditions are prone to life-threatening superinfections. Case: A 51-year-old woman presented with pressing frontal headache accompanied with left periorbital edema, fever, diplopia, and disorientation. Laboratory findings showed low protein C levels. Computed tomography demonstrated sphenoidal rhinosinusitis. Magnetic resonance venography revealed cavernous sinus thrombosis. The patient was started on empiric antibiotic treatment (vancomycin, ceftriaxone, and metronidazole) and anticoagulants. Conclusion: This case report emphasizes the importance of early diagnosis and appropriate management of patients with protein C deficiency complicated by septic cavernous sinus thrombosis. Background: Thrombophilia due to Protein C deficiency is a rare condition, present in 0.2% of general population. Cerebral venous thrombosis has an incidence of 3-4 cases per million in adults. A combination of both is very uncommon. Patients with these conditions are prone to life-threatening superinfections. Case: A 51-year-old woman presented with pressing frontal headache accompanied with left periorbital edema, fever, diplopia, and disorientation. Laboratory findings showed low protein C levels. Computed tomography demonstrated sphenoidal rhinosinusitis. Magnetic resonance venography revealed cavernous sinus thrombosis. The patient was started on empiric antibiotic treatment (vancomycin, ceftriaxone, and metronidazole) and anticoagulants. Conclusion: This case report emphasizes the importance of early diagnosis and appropriate management of patients with protein C deficiency complicated by septic cavernous sinus thrombosis.

Septic Cavernous Sinus Thrombosis in a Young Male Presenting With Pneumothorax Secondary to Septic Pulmonary Emboli: A Case Report

Septic pulmonary embolism (SPE) is a rare complication that happens when infected thrombi from the original site of infection break off and travel to the pulmonary blood vessels, causing an infarction or an abscess. Cases were reported on SPE, with tricuspid or pulmonary valve endocarditis being the most common primary site, especially in intravenous drug abusers. There are, however, very few reports of SPE brought on by septic cavernous sinus thrombosis (CST). Here, we describe the case of an 18-year-old male who had a pustule on his left eyelid, after which he developed fever, spontaneous swelling of his left eye, followed by his right eye, along with bilateral proptosis and diplopia, and new-onset dyspnea. Auscultation revealed decreased breath sounds in the left lung fields. Magnetic resonance imaging (MRI) revealed cavernous sinus thrombosis. Blood cultures isolated Staphylococcus aureus species. High-resolution computed tomography (HRCT) revealed a left-sided pneumothorax with minimal pleural effusion and multiple nodules scattered among both lungs, suggesting septic pulmonary emboli. We report this case to convey how a minor lesion, that is, an eyelid pustule (stye), can get complicated and set off a spiral of events that takes an unexpected tangent, challenging physicians and necessitating a rigorous approach.

Diagnosis and management of orbital and cranial complications of pediatric acute rhinosinusitis

Objective: To review the clinical characteristics, to illustrate diagnosis and management experience of orbital and cranial complications of pediatric acute rhinosinusitis. Methods: The clinical data of 24 children with orbital and cranial complications of acute rhinosinusitis who received endoscopic sinus surgery combined with drug treatment in Beijing Children's Hospital from January 2017 to December 2021 were retrospectively reviewed. There were 19 boys and 5 girls. The age varied from 13 to 159 months, with a median 47.5 months. The following diagnoses were obtained: 12 isolated subperiosteal orbital abscess, 2 associated with preseptal abscess, 2 associated with intraorbital abscess, 7 associated with optic neuritis, and 1 associated with septic cavernous sinus thrombosis. Clinical characteristics, organism isolated and outcomes were analyzed through descriptive methods. Results: All 24 patients presented with fever; 9 presented with nasal congestion and purulent discharge. The clinical manifestations of orbital infection included orbital edema, pain, proptosis and displacement of globe in all patients, while visual impairment was recognized in 7 children. Purulent drainage was cultured in 17 patients, among which 12 were positive. All patients underwent nasal endoscopic surgical interventions uneventfully, excluding one patient who required a second surgical procedure. Follow-up period ranged from 5 to 64 months. All patients resolved fully, with the exception of 2 children who got permanent blindness with visual loss preoperative. There was no recurrence or death. Conclusions: Orbital and cranial complications of pediatric acute rhinosinusitis could be severe with an occult onset. For patients with vison impairment, any signs of intracranial complications and a lack of response to conservative management, an urgent endoscopic intervention is needed.

Septic Cavernous Sinus Thrombosis (CST) with Blindness Caused by Odontogenic Infection – A Case Report

Introduction: Septic cavernous sinus thrombosis (CST) is a rare thrombosis, but severe, causing damage to all nerves inside the cavernous sinus. The incidence rate of CST is estimated at two to four per million people per year. The symptom usually varies, gradually worsening, making diagnosis harder and potentially making permanent disability. Early detection and prompt treatment are very important to lower the morbidity rate. Case: Tn. M had complained of multiple headaches attacks since 8 months ago before being admitted followed by diplopia. Complaints had worsened 3 months before with the loss of vision in the left eye. MRI showed left thrombosis sinus cavernous. The terrible headache was scaled 8-9 with VAS score. The patient’s left eye was found proptosis palpebra, with anisocoria and mydriasis followed by no direct light reflex also indirect light reflex, visual acuity of the left eye is no light response, whereas the patient’s right eye is normal. On the patient’s left eye was found gaze palsy sinistra. The abnormal blood result was leucocytosis and thrombocytosis. The patient was given fondaparinux once a day with a dose of 6000 units subcutaneously for 5 days. After that, the headache was decreased significantly. The patient underwent 5 tooth extraction done by mouth surgeon after being discharged. The patient was given 20 mg rivaroxaban per day for three weeks, then 10mg per day for three months, and evaluated with MRV again. Conclusion: CST is still very rare but very lethal and makes permanent disability on the patient. Through this case, we demonstrate the potential of tooth infection which leads to septic CST and caused ophthalmoplegia and blindness.

Complications of Severe Odontogenic Infections: A Review.

Severe odontogenic infections are routinely treated with little associated morbidity and mortality. Improvements in surgical techniques, antibiotic treatments, and imaging modalities have made associated complications exceedingly rare. A number of complications have been described in the literature including airway obstruction, descending necrotizing mediastinitis, orbital abscess, septic cavernous sinus thrombosis, cerebral abscess, sepsis, necrotizing fasciitis, and Lemierre's syndrome. The purpose of this article is to discuss the pathophysiology of severe odontogenic infections and the risk factors associated with the development of complications. Given the morbidity and mortality of these conditions, it is important to review the clinical features of each and the diagnostic tools that aid in early recognition.

Hypercoagulability and Cavernous Sinus Thrombosis due to Protein C Deficiency. A Case Report.

Background: Thrombophilia due to protein C deficiency is an unusual condition, present in 0.2% of general population. Cerebral venous thrombosis has an incidence of 3-4 cases per million in adults. A combination of both is very uncommon. Patients with these conditions are prone to acquiring life-threatening superinfections. Case: A 51-year-old woman presented to the Emergency Department with bilateral pressing frontal headache accompanied with nausea and vomiting. Laboratory findings, medical history and physical examination were unremarkable. Computed tomography demonstrated sphenoidal rhinosinusitis. Migraine diagnosis was established and treated with analgesics. No treatment for sphenoidal rhinosinusitis was prescribed. Over the next 2 weeks, headaches worsened, and the patient returned to the Emergency Department showing left periorbital edema, fever, diplopia, and disorientation. Laboratory exams showed low protein C levels, elevated procalcitonin and neutrophilia. Magnetic Resonance Venography revealed cavernous sinus thrombosis. The patient was treated with empiric antibiotic treatment (vancomycin, ceftriaxone, and metronidazole) and long-term direct oral anticoagulants (Dabigatran). After one year of the diagnosis, the patient fully recovered and showed no recurrence of thrombotic events. Conclusion: This case report emphasizes the importance of early diagnosis and appropriate management of patients with protein C deficiency complicated by septic cavernous sinus thrombosis.

Cerebral Blood Vessels and Infection

Infectious intracranial aneurysms(IIAs)are rare cerebrovascular complications of systemic infections induced by microbial infiltration and degradation of the arterial vessel wall. Prospective or population-wide studies of the epidemiology, natural history, or management of IIAs have not been conducted. In this study, we present the epidemiological and angiographical features, management, and outcomes of IIAs based on published case series and retrospective studies. Most IIAs were small in size(< 5 mm), with aneurysms located in the middle cerebral artery followed by the posterior cerebral artery. Endovascular interventions for IIAs have increased since coils, liquid embolic materials, and microcatheter became more sophisticated, allowing them to reach more distal branches. Open surgery is still required in cases with large clots or in cases involving branches feeding the eloquent areas, which cannot be sacrificed. These multimodal approaches for managing IIAs have achieved satisfactory results. Septic cavernous sinus thrombosis is also a rare, life-threatening complication of head and neck infections. Several antibiotics and antivirals are used in combination with anticoagulants. However, no consensus has been reached because of a lack of randomized controlled trials and large population-based studies.

Septic Cavernous Sinus Thrombosis Caused by Dental Infection

Purpose: We report a case of bilateral septic cavernous thrombosis caused by a dental infection.Case summary: A 58-year-old male was transferred to our hospital because of left-sided proptosis and eyelid swelling. The patient had fever and left temporal headache, which did not respond to oral and intravenous antibiotics. After experiencing a tooth injury while chewing hard food 3 months ago, the patient developed toothache and swelling around the tooth for which he did not take any treatment. The patient had left eyelid edema, ptosis, chemosis, and conjunctival congestion. The left eye movements were limited in all directions. Brain magnetic resonance imaging showed dilatation and thrombosis of the left superior ophthalmic vein and thrombosis of bilateral cavernous sinuses. The patient was treated with systemic antibiotics and anticoagulants. The blood culture showed growth of Parvimonas micra and Dialister Pneumosintes, which are common causes of dental infection.Conclusions: Septic thrombosis of the cavernous sinus and superior ophthalmic vein thrombophlebitis can occur due to the spread of dental infection. Prompt diagnosis and treatment are important for rapid resolution of symptoms and good prognosis.

Cavernous sinus thrombophlebitis caused by a dental infection: A case report

Septic cavernous sinus thrombosis (CST) is a rare, life-threatening complication of infections of any of the tissues drained by the cavernous sinus such as the mid-face, orbit and sinuses. With the introduction of antibiotics, the mortality and morbidity rates have significantly reduced although they remain high. The necessity of an early diagnosis and appropriate treatment is therefore of great importance. Clinical presentation includes proptosis, chemosis, ocular motor nerve palsy, and sensitive disorders. Imaging investigations, such as contrast enhanced computed tomography (CT) and magnetic resonance imaging (MRI) have had a significant impact on the diagnosis. This condition is rare and after literature review, we found very few case series and some cases reports. We herein share a case of cavernous sinus thrombophlebitis caused by a dental infection.

Septic cavernous sinus thrombosis—Case series and review of the literature

Background and PurposeSeptic cavernous sinus thrombosis (CST) is a rare, life-threatening disease with infectious thrombosis causing associated complications resulting in high morbidity and mortality. We report a series of CST patients with assessment of arterial and intracranial complications. MethodsWe used the radiology database from a large, academic tertiary care center to collect all patients treated with CST between 2002 and 2019. Patient demographics, source of infection, treatment course and outcomes were evaluated. A review of the recent literature was also performed for similar reported complications from CST. Results14 patients with CST treated during this time period were assessed. Of the 14 patients, 1 patient died. 7 patients had unilateral narrowing of ICA while 3 patients had bilateral narrowing. The ICA narrowing was reversible in 10/12 patients and improvement but persistent narrowing in one patient. One patient had an infectious pseudo aneurysm that was treated by coiling. Extension of thrombosis to the transverse- sigmoid sinuses and internal jugular vein were seen in 3 patients. Three patients had subdural empyema which was treated surgically. ConclusionThe prognosis of CST has improved with advancement in treatment, but complications are not infrequent.

Herpes zoster in the ophthalmic branch of the trigeminal ganglia obscuring cavernous sinus thrombosis due to Streptococcus constellatus subsp. constellatus - A case report.

BackgroundHerpes zoster ophthalmicus (HZO) is an infectious disease that results from the reactivation of latent varicella zoster virus in the ophthalmic branch of the trigeminal ganglia. HZO manifests with herpes zoster-like symptoms such as rash with or without signs of ocular involvement. Cavernous sinus thrombosis (CST) is a life-threatening condition accompanied by signs and symptoms involving the eyes and the cranial nerves.CaseWe report a case of septic cavernous sinus thrombosis (caused by Streptococcus constellatus subsp. constellatus) which was masked by the simultaneous occurrence of HZO in this patient, resulting in delayed diagnosis.ConclusionsCST may be obscured by HZO, prompt diagnosis and treatment is necessary when such case arrive.

A Case Report On Septic Cavernous Sinus Thrombosis In A 10 Year Old Rural Fulani Girl From North-Western Nigeria Associated With Bilateral Orbital Cellulitis

Septic Cavernous Sinus Thrombosis (CST) is a rare infective condition affecting the cavernous sinus in the brain associated with high morbidity and mortality, especially when appropriate and prompt intervention is delayed.

The clinical characteristics, implicated pathogens and therapeutic outcomes of culture-proven septic cavernous sinus thrombosis

In this magnetic resonance imaging-based study, we investigated the clinical features, neuroimaging features and therapeutic outcomes of 14 adults (eight men and six women; mean age 60.4 years; range 37–77 years) with septic cavernous sinus thrombosis (CST). Of the underlying conditions, 10 had diabetes mellitus and 13 had concomitant sphenoid sinusitis. Headache (n = 13) and ophthalmoplegia (n = 13) were the most common clinical presentations, followed by fever (n = 9) and other neuro-vascular signs and symptoms. The duration from the onset of symptoms to diagnosis ranged from 1 to 61 days, and more than 64% (9/14) of the septic CST patients were diagnosed >7 days after symptom onset. Expansion of the cavernous sinus was the most common neuroimaging feature, followed by convexity of the lateral wall of the cavernous sinus (5) and filling defect of the cavernous sinus (4). Staphylococcal species (spp.) was the most commonly implicated pathogen, followed by Aspergillus spp. Despite treatment, 7% (1/14) of the patients died in the hospital and 67% (8/12) of the survivors had neurological deficits. The duration of onset-to-diagnosis and the presence of hemiparesis were significant prognostic factors. These results provide a preliminary view of this uncommon infectious syndrome. Further large-scale studies are needed to better delineate septic CST in adults.

Cavernous Sinus Thrombosis due to Chronic Bacterial Sinusitis

The cavernous sinus is the most frequent dural sinus to become infected and thrombosed. Septic cavernous sinus thrombosis has become rare since the advent of antibiotics. We herein present a case of septic cavernous sinus thrombosis caused by chronic bacterial sinusitis.

Fatal septic cavernous sinus thrombosis following dental extraction: a case report

AbstractCavernous sinus thrombosis is a rare complication of odontogenic infection. A coexistence of compromised medical condition would reduce the patient survivability. In this context, we reported a 66‐year‐old female who developed an odontogenic infection and cavernous sinus thrombosis within 1 day after an upper tooth extraction. Considered as a life‐threatening complication status of odontogenic infection, the patient was referred to the emergency medicine department for intensive care with differential diagnosis of cavernous sinus thrombosis and masticator space infection. It was revealed that the patient had an uncontrolled diabetes mellitus and acute kidney injury. Later the patient developed a septic shock and died in almost 2 days since the tooth extraction. This makes it very important for the dentists to raise suspicion of uncontrolled status in those patients with history of diabetes mellitus and manage them carefully with proper antibiotic cover when undergoing dental procedures.

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

PurposeSeptic 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.MethodsUsing 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.ResultsWe 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.ConclusionsThe 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 Cavernous Sinus Thrombosis Following a Minor Head Injury: A Rare Cause of Medico‐Legal Death

Septic cavernous sinus thrombosis (SCST) is an uncommon consequence of head and face infection, but a rare complication after craniofacial fracture. In this case, SCST developed in a 13-year-old girl following a minor fall during volleyball, with impact and resulting abrasive contusion of the left forehead. She developed watery rhinorrhea, progressive headache, fever, nausea, vomiting, and left proptosis with blurred vision, and was admitted to hospital 3days after injury. Drowsiness, high-grade fever, severe headache, left ocular pain with marked periorbital swelling, and paralysis of extraocular eye movements developed. Computed tomography scan identified left sphenoid and ethmoid sinusitis, a posterior clinoid fracture, and septic cavernous sinus thrombosis. She died after 10days of in-hospital antibiotic therapy. Death was due to Staphylococcus aureus sepsis with septic pulmonary thromboemboli due to suppurative meningitis and cerebral infarction, due to SCST following apparently minor blunt head injury from an accidental fall.

Septic thrombosis of cavernous sinus extended to the ipsilateral internal jugular vein and transversal sinus with favorable outcome: Clinical and radiological features of a Lemierre syndrome

ABSTRACTAn 86-year-old patient was hospitalized for fever and left acute orbital syndrome (red eye with moderate visual impairment, chemosis, ophthalmoplegia without proptosis, or any fundus involvement). CT scan showed superior ophthalmic vein and cavernous sinus enlargement complicating ipsilateral sphenoidal sinusitis. Magnetic resonance imaging (MRI) demonstrated the left cavernous sinus thrombosis extended to the ipsilateral jugular vein and transversal sinus (Lemierre syndrome). Intravenous broad-spectrum antibiotics and curative anticoagulation were prescribed. Blood cultures allowed the identification of Streptococcus intermedius and Staphylococcus warneri species. Evolution was favorable and the patient was discharged 3 weeks after. Antibiotics and anticoagulation were carried out for a total duration of 4 and 12 weeks, respectively. Lemierre syndrome is a potentially life-threatening emergency rarely encountered; thus, ophthalmologists should be cognizant of clinical and radiological features. Broad-spectrum antibiotics are the mainstay of treatment. Curative anticoagulation may be added if no blood coagulation disorder nor bleeding on neuroimaging has been identified.