Septic cavernous sinus thrombosis

Septic cavernous sinus thrombosis (SCST) is a rare, yet severe, thrombophlebitic process typically arising from infections of the paranasal sinuses 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 pre-antibiotic 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 sequelae, highlighting the severity of the disease and the need for prompt recognition, diagnosis, and treatment ¹⁾.

Head trauma as a predisposing factor of SCST has been scarcely reported ²⁾

Staphylococcus aureus and Streptococcus are often the associated bacteria.

Due to the high case-fatality rate and low yield rate of blood cultures, fungal CST should be suspected in an immunocompromised patient with ophthalmic complaints that progress from one eye to the other. Coronal thin-section CECT may be a useful alternative to MRI as a diagnostic modality for this condition ³⁾.

Treatment entails early administration of broad-spectrum intravenous antibiotics, anticoagulation, and surgical drainage when applicable ⁴⁾.

There are no randomized, controlled trials of management of this condition and existing reviews of the literature are somewhat dated.

Outcome data suggest that corticosteroids are of equivocal benefit whereas antibiotics and anticoagulation are beneficial ⁵⁾.

Before the availability of antimicrobial agents, mortality from CST was near 100%, but it markedly decreased to approximately 20% to 30% during the antibiotic era. Nevertheless, the threat of death and serious morbidity continues to necessitate early recognition, diagnosis, and treatment of CST to minimize risks to the patient ⁶⁾.

Retrospective case series of 6 patients identified with septic cavernous sinus thrombosis and orbital cellulitis confirmed by magnetic resonance imaging at a tertiary care center from January 1980 to December 2016. Medical records were reviewed for demographics, risk factors, symptoms, etiology, radiographic diagnosis, complications, treatments, and outcomes. In addition, a literature review was performed from 2005 to 2018, and 119 cases of septic cavernous sinus thrombosis confirmed by imaging were included for aggregate comparison. This study adheres to the tenets of the Declaration of Helsinki, and institutional review board approval was obtained.

Results: All 6 cases presented with headache, fever, ocular motility deficit, periorbital edema, and proptosis. The primary source of infection included sinusitis (n = 4) and bacteremia (n = 2). Identified microorganisms included methicillin resistant Staphylococcus aureus (n = 3) and Streptococcus anginosus (n = 1). All cases were treated with broad-spectrum intravenous antibiotics and anticoagulation, and one case underwent endoscopic sinus surgery. The mean time between initial presentation to diagnosis of cavernous sinus thrombosis was 2.8 days, and the average length of hospital admission was 21 days. The mortality rate was 0%, but 4 cases were discharged with neurological deficits including vision loss (n = 1) and ocular motility disturbance (n = 3). Literature review produced an additional 119 cases.

Early diagnostic imaging with contrast-enhanced CT or MRI should be initiated in patients with risk factors and ocular symptoms concerning cavernous sinus thrombosis. Treatment entails early administration of broad-spectrum intravenous antibiotics, anticoagulation, and surgical drainage when applicable ⁷⁾.

Nine patients with septic CST who had typical symptoms and clinical course, evidence of infection, and imaging studies that demonstrated cavernous sinus lesion, and who were treated between 1995 and 2003 at National Taiwan University Hospital.

Results: Seven (77.8 %) patients were more than 50 years old. Five (55.6%) had diabetes, and three (33.3%) had hematologic diseases. All cases were associated with paranasal sinusitis. The most frequent initial symptom was headache (66.7%), followed by ophthalmic complaints (diplopia or ophthalmoplegia, 55.6%; blurred vision or blindness, 55.6%), and ptosis (44.4%). Initial cranial images failed to identify CTS in all patients. Subsequent magnetic resonance imaging (MRI) or coronal contrast-enhanced CT (CECT) with thin sections confirmed the diagnosis. Fungi were the most common pathogens (55.6%). The in-hospital case-fatality rate was high (44.4%).

Due to the high case-fatality rate and low yield rate of blood cultures, fungal CST should be suspected in an immunocompromised patient with ophthalmic complaints that progress from one eye to the other. Coronal thin-section CECT may be a useful alternative to MRI as a diagnostic modality for this condition ⁸⁾.

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 ⁹⁾.

A case report of acute otitis media that led to septic cavernous sinus thrombosis in a 56-year-old woman in Bojnord city, North Khorasan, Iran.

Findings of laboratory tests and magnetic resonance imaging (MRI) confirmed the clinical diagnosis. Clinical-based medical care led to successful management of the patient with broad-spectrum intravenous antibiotics that prevented serious complications ¹⁰⁾.