Septic Cavernous Sinus Thrombosis Due to Sphenoid Sinusitis
Septic Cavernous Sinus Thrombosis Due to Sphenoid Sinusitis
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 that her symptoms were due to the road traffic accident. When her condition worsened, she presented to the emergency department. On examination, she was anxious and had neck stiffness but was generally well and apyrexial. Neurological examination was normal. She was admitted via the paediatric clinic for observation, analgesia and investigations. Her white cell count was 14 300×10/litre (4.0–11.0) with neutrophilia and serum C-reactive protein was >320 mg/l (<10). Spinal x-ray was normal. She was started on intravenous ceftriaxone and oral metronidazole.
She developed right periorbital oedema and photophobia (figure 1). On examination, her visual acuity was 6/6 bilaterally with right hemifacial oedema, right-sided ptosis and limited right eye movements. There was resistance on retropulsion and also dilatation of the superior episcleral vessels on the right eye (figure 2). Intraocular pressure was normal and optic discs healthy. Both pupils reacted sluggishly but there was no relative afferent pupillary defect.
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Figure 1.
Right periorbital and facial oedema and a right ptosis in an unwell patient.
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Figure 2.
Right dilated superior episcleral vessels due to orbital venous congestion.
Contrast-enhanced CT and gadolinium-enhanced MRI of brain showed expansion and a filling defect in the cavernous sinus and pituitary fossa (figure 3). There was also expansion of the right superior ophthalmic vein with a filling defect (figure 4), in keeping with cavernous sinus thrombosis extending into the superior ophthalmic vein. There was evidence of acute sphenoid sinusitis (figure 5), with pus visible on the diffusion-weighted images; this was considered to be the cause of the cavernous sinus thrombosis. Blood culture grew Streptococcus intermedius.
(Enlarge Image)
Figure 3.
Coronal T1 MRI postgadolinium enhancement: demonstrates expansion and filling defect in the cavernous sinus (arrows).
(Enlarge Image)
Figure 4.
Coronal CT reconstruction postcontrast showing dilated right superior ophthalmic vein (arrow) containing thrombus. Compare with the normal left superior ophthalmic vein (arrowhead).
(Enlarge Image)
Figure 5.
Axial T2 MR showing inflammation in both sphenoid sinuses (arrows).
She continued to receive intravenous antibiotics and a subcutaneous low-molecular-weight heparin (tinzaparin) was added. She recovered fully over several few months. Repeat MR brain scan at 10 weeks showed normal cavernous sinus opacification (figure 6).
(Enlarge Image)
Figure 6.
Coronal T1 postgadolinium MRI performed 10 weeks later showing resolution of the cavernous sinus thrombosis with normal enhancement.
Case Report
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 that her symptoms were due to the road traffic accident. When her condition worsened, she presented to the emergency department. On examination, she was anxious and had neck stiffness but was generally well and apyrexial. Neurological examination was normal. She was admitted via the paediatric clinic for observation, analgesia and investigations. Her white cell count was 14 300×10/litre (4.0–11.0) with neutrophilia and serum C-reactive protein was >320 mg/l (<10). Spinal x-ray was normal. She was started on intravenous ceftriaxone and oral metronidazole.
She developed right periorbital oedema and photophobia (figure 1). On examination, her visual acuity was 6/6 bilaterally with right hemifacial oedema, right-sided ptosis and limited right eye movements. There was resistance on retropulsion and also dilatation of the superior episcleral vessels on the right eye (figure 2). Intraocular pressure was normal and optic discs healthy. Both pupils reacted sluggishly but there was no relative afferent pupillary defect.
(Enlarge Image)
Figure 1.
Right periorbital and facial oedema and a right ptosis in an unwell patient.
(Enlarge Image)
Figure 2.
Right dilated superior episcleral vessels due to orbital venous congestion.
Contrast-enhanced CT and gadolinium-enhanced MRI of brain showed expansion and a filling defect in the cavernous sinus and pituitary fossa (figure 3). There was also expansion of the right superior ophthalmic vein with a filling defect (figure 4), in keeping with cavernous sinus thrombosis extending into the superior ophthalmic vein. There was evidence of acute sphenoid sinusitis (figure 5), with pus visible on the diffusion-weighted images; this was considered to be the cause of the cavernous sinus thrombosis. Blood culture grew Streptococcus intermedius.
(Enlarge Image)
Figure 3.
Coronal T1 MRI postgadolinium enhancement: demonstrates expansion and filling defect in the cavernous sinus (arrows).
(Enlarge Image)
Figure 4.
Coronal CT reconstruction postcontrast showing dilated right superior ophthalmic vein (arrow) containing thrombus. Compare with the normal left superior ophthalmic vein (arrowhead).
(Enlarge Image)
Figure 5.
Axial T2 MR showing inflammation in both sphenoid sinuses (arrows).
She continued to receive intravenous antibiotics and a subcutaneous low-molecular-weight heparin (tinzaparin) was added. She recovered fully over several few months. Repeat MR brain scan at 10 weeks showed normal cavernous sinus opacification (figure 6).
(Enlarge Image)
Figure 6.
Coronal T1 postgadolinium MRI performed 10 weeks later showing resolution of the cavernous sinus thrombosis with normal enhancement.
