Septic Cavernous Sinus Thrombosis Research Articles

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.

Cavernous Sinus Thrombosis

Cavernous sinus thrombosis (CST) is a rare diagnosis although must be included in the differential of headache. CST is either infectious or aseptic. Aseptic thrombosis usually occurs secondary to trauma or is post surgical. Sinusitis appears to be the most common cause for septic CST. Otitis media, facial cellulitis (located medial third paranasal) and odontogenic infections are also commonly implicated. Cavernous sinus thrombosis (CST) is a rare phenomenon that requires clinical suspicion and emergent imaging for correct diagnosis. Mycotic aneurysm is a rare complication of cavernous sinus thrombosis and may be treated with antibiotics, carotid ligation, internal carotid artery balloon occlusion, or Guglielmi detachable coil (GDC) embolization.

Danger Triangle of Face and Septic Cavernous Sinus Thrombosis

Danger Triangle of Face and Septic Cavernous Sinus Thrombosis

A Severe Case of Septic Cavernous Sinus Thrombosis Caused by a Rare Pathogen

SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Cavernous Sinus Thrombosis (CST) is thrombophlebitis in the cavernous sinuses. Before the availability of antibiotics, this dramatic and lethal illness carried a 100% mortality, therefore, the onus is on the clinician to have early recognition of this disease and treatment options, which include antibiotics, anticoagulation, and surgery. Although there have been case reports of CST as a complication of paranasal sinusitis, otitis media, and pharyngitis in pediatric population, literature review reveals few cases of CST in adults causing multi-organ impairment similar to our patient. We report a case of CST causing cranial nerve palsy and internal carotid artery narrowing from ethmoid and sphenoid sinusitis secondary to Group C, Beta Hemolytic Streptococcus. This is a common flora of upper airways and skin and bacteremia is almost always seen in immunocompromised individuals and rarely seen in an immunocompetent patient like ours. CASE PRESENTATION: 36 year old female with no significant past medical history presented to the ED with a three day history of left sided headaches, subjective fevers, diplopia and left periorbital swelling. On exam, she was febrile with left eye proptosis and left lateral gaze palsy. Labs revealed significant leukocytosis with left shift and elevated inflammatory markers. CTA head and neck showed left cavernous sinus thrombosis/thrombophlebitis as well as narrowing of left internal carotid artery with MRI/MRV confirming these findings. Imaging also revealed bilateral complete opacification of sphenoid and ethmoid cells suggestive of severe sphenoiditis and ethmoiditis. She was admitted to ICU and her course was complicated by septic shock and acute hypoxemic respiratory failure requiring pressors and mechanical ventilation as per ARDS protocol. Further septic workup revealed the patient to have beta hemolytic, group C strep bacteremia with nasal culture showing the same speciation. She was started on IV antibiotics and heparin drip in ICU and was later discharged home on oral warfarin and IV ceftriaxone. DISCUSSION: The likely mechanism in our patient is that she initially had ethmoiditis causing orbital inflammation and thrombophlebitis of the ophthalmic vein, which extended posteriorly to cause septic CST. Literature review shows that S. aureus encompasses two-thirds of the cases followed by streptococci, especially pneumococci, but there have been no cases, to our knowledge, of group C beta hemolytic strep causing CST. CONCLUSIONS: Aggressive multidisciplinary approach to management remains key in these patients due to high mortality if there is a delay in early and proper diagnosis. Sinusitis and ethmoiditis are relatively common and a physician should be aware of the potential adverse consequences, especially in the setting of ptosis, proptosis, and external opthalmoplegia. Reference #1: Hiroshi Sakaida, Masayoshi Kabayashi, Ai Ito. Cavernous Sinus Thrombosis: linking a swollen red eye and headache. Lancet 2014: 384: 928 DISCLOSURE: The following authors have nothing to disclose: Hemal Mehta, Anthony Saleh, Ravish Singhal No Product/Research Disclosure Information

Periodontitis Associated With Septic Lateral Sinus Thrombosis and Pulmonary Embolism

A 42-year-old woman had acute headache and intermittent fever for 1 month. Neuroimaging revealed acute venous thrombosis in the left transverse and sigmoid sinuses. Cerebrospinal fluid analysis showed increased protein, reduced glucose and leukocytosis. Blood culture yielded Peptostreptococcus, which was highly suspected due to the patient having periodontitis. Meanwhile, multiple pulmonary emboli were detected during the course of treatment. The patient recovered well after antibiotic therapy followed by dental treatment. Dental diseases may cause septic cavernous sinus thrombosis, but their association with lateral sinus thrombosis has not been previously reported. This case report describes the unusual presentation of lateral sinus thrombosis and multiple pulmonary emboli in a patient with periodontitis, and demonstrates that oral cavity can be the primary infection focus, and dental evaluation should be considered for patients with cerebral venous sinus thrombosis.

Septic cavernous sinus thrombosis secondary to acute bacterial sinusitis: a retrospective study of seven cases.

Septic cavernous sinus thrombosis (SCST) is a rare but severe complication of acute bacterial sinusitis. Evaluations of advances in imaging techniques as well as in medical and surgical treatment are hampered by the lack of recent studies. We aim to report our experience in the management of SCST in patients with acute bacterial sphenoid sinusitis over the past 10 years and to discuss the initial work-up and treatment strategies. We performed a retrospective study of patients admitted for SCST related to acute sinusitis at a tertiary care center between 2003 and 2013. Clinical charts were reviewed for demographics, clinical presentations, imaging and microbiologic findings, medical and surgical treatments, and outcomes. Seven patients were treated for SCST. Sphenoid sinus was involved in all cases. The most frequent presenting signs included headache (100%), cranial nerve impairment (86%), fever (71%), and orbital symptoms (71%). Diagnosis was confirmed by a cerebral contrast-enhanced CT scan in all cases. Four patients (57%) had an additional intracranial complication. The average time between clinical onset and diagnosis was 13.7 days. All patients were treated by high-dose i.v. antibiotics, anticoagulation therapy, and surgical endoscopic drainage of the infected sinuses. This treatment strategy resulted in a mortality rate of 0%, but four out of the seven patients developed transient or permanent neurologic deficits, including one with permanent unilateral visual loss. The combination of high-dose i.v. antibiotics, anticoagulation therapy, and endoscopic drainage of the infected paranasal sinus is an effective strategy for the treatment of SCST, but long-term sequelae remain frequent.

Septic cavernous sinus thrombosis secondary to a mycotic pseudoaneurysm of a cubital arteriovenous fistula

Introduction: The cavernous sinuses are part of the dural sinuses. In 1831, Bright described cavernous sinus thrombosis (CST) as a complication of epidural and subdural infections. Cavernous sinus thrombosis usually results as a complication of paranasal sinus infection or infections of the face, in an area called the 'danger triangle', trauma, bacteremia or ear infections. Case Report: A 35-year-old female presented with one month history of high grade fever and progressively increasing periorbital swelling. This presentation was preceded by failure and infection of her arteriovenous fistula (AVF) three weeks beforehand, which was resistant to medical therapy. On examination, she was febrile and had periorbital swelling with bilateral closure of the eyes. The left jugular vein was distended. At the site of the AVF, there was a pulsatile swelling which was also discharging pus. Following aneurysmectomy and AVF ligation, an angiogram of the head and neck showed a long segment occlusion on the left internal jugular vein extending to the left brachiocephalic vein plus a cavernous sinus thrombus. A diagnosis of a septic CST was made and management was conservative. We report this case because, to the best of our knowledge, no literature was found describing a mycotic AVF complicated by a jugular and brachiocephalic vein thrombosis causing a septic CST. Conclusion: In patients presenting with a mycotic AVF, the risk of developing a septic CST should be kept in mind. The goal of intervention should be to control the source of infection and prevent complications.

The Case Files

A 37-year-old man with no significant medical history presented to the emergency department with a headache. He described it as an insidious, constant severe pain that was initially localized occipital but progressed to a bitemporal distribution. His neurologic exam, extraocular movements, and visual acuity were all normal. The patient was given symptomatic treatment with compazine and Benadryl. He was responsive to therapy and discharged home after his headache symptoms resolved. Seven days later, however, he presented to the emergency department with a worsening headache, progressive altered mental status, fever, and bilateral proptosis. His temperature was of 103.9°F, blood pressure was 194/82 mm Hg, pulse rate was 87 bpm, and oxygen saturation was 98%. His exam was significant for profound bilateral periorbital edema with significant chemosis, drainage, and overlying erythema. (Figure 1.)Figure 1: Patient with profound periorbital swelling and significant chemosis with overlying erythema and drainage.The right eye was impossible to examine because of significant swelling. The extraocular muscles in the left eye were limited in all directions, and pupils were sluggish. Computed tomography without contrast of the head and orbit demonstrated an enlargement of the right superior ophthalmic vein, attenuation of the right sigmoid sinus, subtentorial collection, paranasal sinus disease, and severe bilateral proptosis with periorbital soft tissue swelling. (Figure 2.) The patient was treated empirically with intravenous antibiotics and admitted for suspected septic cavernous sinus thrombosis with periorbital cellulitis.Figure 2: Head and orbit computed tomography without contrast. A. Paranasal sinusitis including sphenoid and ethmoid sinuses (straight red arrows) with periorbital edema with proptosis (curved red arrow). B. Supraopthalmic vein enlargement. C. Hypoattenuation of right sigmoid sinus as compared with left. D. Extra-axial hypoattenuation under the right tentorium.Lateral canthotomy and cantholysis were performed after admission to relieve his elevated intraocular pressure, followed by an emergent orbital depression by total ethmoidectomy and sphenoid sinusotomy. The patient also suffered from meningitis and recurrent subdural empyemas, which required multiple subdural drains and neurosurgical interventions, including placement of a VP shunt for obstructive hydrocephalus. Cultures grew Streptococcus anginosis and Streptococcus viridins, and Propionibacterium, and antimicrobial therapy was titrated to penicillin G, which resulted in clinical improvement and infection clearance. The patient was discharged to a rehabilitation facility with complications, including blindness in the right eye and a permanent VP shunt. Dural venous thrombosis is caused by thrombosis of a cerebral vein or occlusion of dural sinuses. (Medicine 1986;65[2]:82; Arch Intern Med 2001;161[22]:2671.) The cavernous sinus is the most frequent dural sinus to become thrombosed secondary to infection because of its irregular trabecular structure that allows bacterial trapping. (J Neurosurg 1976;45[2]:169.) It is a rare disease with serious sequelae, including a 30 percent mortality rate, spread of infections such as meningitis and cerebral abscesses, persistent oculomotor weakness, blindness, hemiparesis, and pituitary insufficiency. (N Engl J Med 1983;309[19]:1149.) The prevalence of septic cavernous sinus thrombosis is most common among men (21% vs 10%), mainly because of a higher frequency of ear, nose, and throat infections in this population. (Stroke 2009;40[7]:2356.) Sinusitis, most commonly sphenoid and ethmoid infections, is a common nidus in infections that preclude cavernous sinus thrombosis. Facial infections drained by the ophthalmic vein and dental infections drained by the pterygoid venous plexus also put patients at risk for this complication. (Orbit 2006;25[1]:39.) Sphenoid sinus infections typically spread contiguously through the lateral air sinus wall, while ethmoid sinus infections extend laterally to the orbital cavity with subsequent extension to the ophthalmic veins. (N Engl J Med 1983;309[19]:1149.) The intricate structure of the cavernous sinuses creates a potential location for trapping, seeding, and proliferation of microorganisms. This results in thrombosis and stasis of dural venous return from the ophthalmic and cerebral veins. The venous status leads to increased capillary pressure with subsequent decreased cerebral perfusion, leakage into the interstitial parenchyma, and cytotoxic edema. (Neuroradiology 2002;44[6]:481; Arch Neurol 2001;58[10]:1569.) Early signs and symptoms of cavernous sinus thrombosis are nonspecific, and they usually mimic primary headache syndromes. Headaches are the most common early sign, followed by fever, proptosis, chemosis, altered mental status, and cranial nerve III and VI palsies. Brain MRI is the most sensitive and specific imaging modality for cavernous sinus thrombosis, but head CT scan and lumbar puncture are useful to evaluate the emergent or unstable patient. Mainstay therapy is broad-spectrum antibiotics with meningitis dosing, along with anticoagulation, glucocorticoids, and surgical drainage. (Pediatr Crit Care Med 2004;5[1]:86; J Laryngol Otol 2002;116[9]:667.) Septic cavernous sinus thrombosis is relatively rare but the prognosis of patients is relatively poor. Many patients can initially present with nonspecific symptoms, with the most common mimicking primary headache syndromes. Therefore, it is important for the emergency medicine physician to consider septic cavernous sinus thrombosis patients presenting with headache, especially in patients with a history of chronic sinusitis.

Septic cavernous sinus thrombosis

AbstractAlthough septic cavernous sinus thrombosis represents a rare cerebral vascular event, the morbidity and mortality can be profound. Diagnosis of this disease remains challenging, despite recent advances in imaging technology. We present a 71‐year‐old man who presented with symptoms of retro‐orbital pain, swelling and a recent history of being treated for bacterial sinusitis. An initial non‐contrast head computed tomography showed a dilated, hyperdense appearance of his left superior ophthalmic vein, with subsequent magnetic resonance imaging suggestive of bilateral ophthalmic vein thrombosis likely from cavernous sinus origin. The patient had blood cultures positive for Streptococcus anginosus, and was successfully treated with several weeks of i.v. antibiotics and anticoagulation.

Necrotizing fasciitis of the nose complicated with cavernous sinus thrombosis.

Necrotizing fasciitis is a rapidly progressive life threatening bacterial infection of the skin, the subcutaneous tissue, and the fascia. We present a case of necrotizing fasciitis involving the nose complicated by cavernous sinus thrombosis. Few cases of septic cavernous sinus thrombosis have been reported to be caused by cellulitis of the face but necrotizing fasciitis of the nose is rare. It is very important to recognize the early signs of cavernous thrombosis. Treatment for septic cavernous sinus thrombosis is controversial but early use of empirical antibiotics is imperative.

Septic Cerebral Vein Thrombosis and Abnormal Leptomeningitis as a Complication From a Periodontitis in a Hispanic Male: Case Report and Literature Review

Sinus vein thrombosis is a rare form of stroke that results from thrombosis of the dural vein sinus. Despite the variety of diagnostic procedures and treatment, septic thrombosis of the cavernous sinus can cause significant morbidity and mortality if not diagnosed and treated as an emergency. The clinical presentation of proptosis that occurs suddenly accompanied by erythema of the eyelid and limitation of ocular movement should alert the clinician of the possibility of cavernous sinus thrombosis. A 38-year old Hispanic male presented with pounding headache, mainly in the occipital region that began 1 week prior to hospital admission. During the hospitalization the patient subsequently developed a progressive worsening of proptosis, lacrimation and neck pain. The MRI and venography of the brain showed a cerebral venous thrombosis (CVT) with a reactive diffuse leptomeningitis. The underlying cause was a chronic dental infection. The patient was treated with course of antibiotics and discharged. A few weeks later the repeated imaging studies showed a resolution of the CVT and leptomeningitis. Although rare, septic vein thrombosis (SVT) remains a potentially lethal complication of infections that involve the sinuses, face, ears and oral cavity. The early recognition and differentiation from other diseases are keys to reducing mortality rates and long-term sequelae. Advances in imaging, especially CT and MRI have contributed substantially to the rapid diagnosis of the condition. J Med Cases. 2013;4(9):598-601 doi: http://dx.doi.org/10.4021/jmc1370w

Lessons from everyday practice: septic cavernous sinus thrombosis due to sphenoid sinusitis in a young patient following a road traffic accident

A 15-year-old girl gave a 2-week history of worsening neck pain and headache. Three weeks before she had sustained minimal injury in a car accident. She took simple analgesics, suspecting...

A Case of Bilateral Septic Cavernous Sinus Thrombosis after Facial Trauma

Purpose: We report a case of a patient with ptosis, lid swelling, limitation of ocular movement, and visual disturbance after a trauma. The patient was diagnosed with unilateral orbital cellulitis, ophthalmic vein thrombosis and bilateral septic cavernous thrombosis and treated. Case summary: After head and facial area trauma that occurred 1 month earlier, a 56-year-old man suffered from ongoing visual loss, limitation of ocular movement in all directions, proptosis in the left eye and abduction limitation of the right eye. A week before admission, mild fever and chills were also present. At admission, visual acuity of the left eye was no light perception and pupil reflex was lost. Brain MRA and MRI indicated dilation and thrombosis of the left superior ophthalmic vein, left orbital cellulitis and inflammation in bilateral cavernous sinuses. The patient was immediately treated with systemic antibiotics and steroid injection. Coagulase negative staphylococci were detected in blood culture. Conclusions: Infection caused by facial trauma spread through the facial area’s venous plexus and caused orbital cellulitis. As a result, septic cavernous sinus thrombosis and ophthalmic vein thrombophlebitis occurred. Serious complications can occur after facial trauma, thus rapid differential diagnosis and appropriate treatment are important in determining prognosis. J Korean Ophthalmol Soc 2013;54(4):662-666

Bilateral cavernous sinus thrombosis and facial palsy as complications of dental abscess

Septic cavernous sinus thrombosis (CST) related to dental infection is a rare clinical event. The septic CST is a disease of high morbidity and mortality. The prompt diagnosis and timely treatment of septic CST is cornerstone of successful outcome. The dental infection should be given due attention, as to prevent CST. In this case report of immunocompetent female, we highlighted the role of dental abscess in producing bilateral CST and facial palsy. The close collaboration between dentist and neurologist and early institution of antibiotics led to complete recovery at follow-up after 3 months. The dental infection should never be neglected as it is the interface of serious intracranial complication like CST.

Septic Cavernous Sinus Thrombosis Complicated by Occlusion of the Internal Carotid Artery and Multiple Embolic Strokes After Surgery of an Anorectal Abscess

Septic thrombosis of the cavernous sinus (CST) is a rare and potentially life-threatening condition mostly caused by facial or ear, nose, and throat infections. Anatomic structures in vicinity of the cavernous sinus are thereby susceptible to inflammatory damage. In particular nervous system structures are almost regularly affected; however, only few authors reported severe involvement of the internal carotid artery (ICA). We present an atypical clinical course of CST in a 61-year-old male diabetic patient caused by a distant focus of inflammation. Septic CST after surgical treatment of an anorectal abscess was complicated by occlusion of the ICA and multiple embolic strokes. The diagnosis was established by magnetic resonance imaging scan, symptoms resolved after antibiotic therapy and heparin anticoagulation. The presented case and review of literature emphasizes the variability of signs and clinical course of CST, a frequent cause of delayed diagnosis. Especially in immunocompromised patients, the primary source of CST may be a distant inflammatory focus with nonspecific and subacute symptoms. Septic CST can be a rare cause of ischemic stroke when complicated by ICA occlusion because of septic arteritis. Expedited diagnostic workup is necessary and rests upon radiologic investigations.

Septic superior ophthalmic vein and cavernous sinus thrombosis in children

Septic superior ophthalmic vein and cavernous sinus thrombosis in children

Challenging presentations of cavernous sinus thrombophlebitis

AimThe purpose of this study was to describe two challenging cases of septic cavernous sinus thrombosis (CST), which presented with vastly different clinical signs and symptoms.MethodsWe present two cases of CST with markedly differing clinical presentations, medical comorbidities, and degree of impairment. Initial imaging of each patient failed to show thromboembolic disease.ResultsBoth patients required multiple imaging procedures to arrive at the correct diagnosis. Each child did respond to treatment once the correct diagnosis was made.ConclusionCST can have a highly variable clinical presentation, from a subtle sixth nerve palsy to complete ophthalmoplegia and loss of periorbital sensation and corneal reflex. Onset of symptoms may be acute and fulminant or indolent and delayed. The diagnosis is challenging, requiring clinical suspicion and confirmation by imaging. These cases illustrate the importance of retaining clinical suspicion when cranial nerve palsies persist and how valuable rescanning a patient can be.

Diffusion restriction in thrombosed superior ophthalmic veins: Two cases of diverse etiology and literature review

Thrombosis of superior ophthalmic veins (SOV) is a well known entity occurring secondary to varied etiologies. We describe diffusion restriction in thrombosed SOV in two cases of different etiologies- bilateral involvement in a patient with septic cavernous sinus thrombosis (CST) and another where embolisation of an indirect carotico-cavernous fistula (CCF) resulted in complete SOV thrombosis accompanied by clinical worsening. Our cases add to the limited literature on diffusion findings in SOV thrombosis.