When the Problem Became the Solution.

We present a unique case where a young man developed subtle cavernous sinus thrombosis (CST) due to underlying hypercoagulable state. He also had coexisting frontal lobe brain dural arteriovenous fistula (bdAVF). After CST developed, venous drainage from the optic nerve was redirected into the frontal lobe which was already under high venous pressure because of preexisting bdAVF. This caused backflow of venous blood into the optic nerve causing massive persistent optic nerve head swelling. Presumed acute venous hypertension event within bdAVF caused frontal mass effect presenting as seizure leading to thrombosis of bdAVF.

Comment faire d'un problème une solution. Nous voulons présenter ici le cas unique d'un jeune homme chez qui une thrombose du sinus caverneux s'est développée en raison d'une condition sous-jacente d'hypercoagulabilité. Ajoutons également que le lobe frontal de son cerveau donnait à voir des fistules artério-veineuses durales. Une fois développé ce type de thrombose, on a procédé à un drainage veineux à partir du nerf optique, drainage ensuite redirigé dans le lobe frontal, lequel faisait déjà face à des conditions de pression veineuse élevée à cause de ces fistules. Cela a entraîné le refoulement de sang veineux dans le nerf optique, ce qui a provoqué en retour une grave et persistante enflure de la tête du nerf optique. À cet égard, on peut présumer qu'une manifestation aigüe d'hypertension veineuse dans ces fistules a causé l'apparition de cet effet de masse du lobe frontal se manifestant par des crises convulsives, ce qui a fini par engendrer la thrombose des fistules artério-veineuses durales.

Trombosis del seno cavernoso derecho secundaria a rinosinusitis esfenoidal: reporte de caso / Right cavernous sinus thrombosis secondary to sphenoidal rhinosinusitis: case report

RESUMEN La rinosinusitis bacteriana aguda es la infección de la mucosa nasal y de senos paranasales, que se manifiesta con congestión nasal, rinorrea purulenta y fiebre, de curso generalmente autolimitado. La trombosis del seno cavernoso (TSC) es una complicación poco frecuente, que se asocia a compromiso del seno esfenoidal y etmoidal, manifestándose clínicamente con cefalea, fiebre, alteración de pares craneanos y síntomas oculares. Ante su sospecha el estudio imagenológico es fundamental. En estos exámenes se debe buscar un defecto de llene en el seno cavernoso comprometido. El tratamiento debe iniciarse de forma precoz y contempla: antibioticoterapia, drenaje quirúrgico del seno afectado y anticoagulación. Se presenta a un paciente pediátrico masculino con TSC derecha posterior a una rinosinusitis esfenoidal no tratada, que respondió favorablemente al tratamiento. Se describe la clínica y manejo de esta patología, que presenta alta morbimortalidad, y que puede disminuirse considerablemente con un tratamiento precoz y agresivo.

ABSTRACT Acute bacterial rhinosinusitis is the infection of the nasal and paranasal mucous membrane, with symptoms such as nasal congestion, purulent rhinorrhea and fever, usually self-limiting. Cavernous sinus thrombosis (CST) is a rare complication, which is associated with sphenoid and ethmoid sinus involvement, clinically manifest with headache, fever, cranial nerve involvement and ocular symptoms. When suspected, imaging studies will confirm the clinical impression. They will show abnormal flow parameters in the compromised cavernous sinus. The treatment has to start as soon as possible and consists in broad spectrum intravenous antibiotics, surgical drainage of the site of the infection and anticoagulation. We present a patient with a right CST secondary to a non-treated sphenoidal sinusitis, that responded favorably to treatment. The clinical and management of this pathology is described, which presents a high morbidity and mortality that can be reduced considerably with an early and aggressive treatment.

Use of ventriculostomy in the treatment of septic cavernous sinus thrombosis (SCST).

We present a novel treatment with the use of intraventricular antibiotics delivered through a ventriculostomy in a patient who developed septic cavernous sinus thrombosis after sinus surgery. A 65-year-old woman presented with acute on chronic sinusitis. The patient underwent a diagnostic left maxillary antrostomy, ethmoidectomy, sphenoidotomy and sinusotomy. Postoperatively, the patient experienced altered mental status with episodic fever despite treatment with broad-spectrum antimicrobial therapy. MRI of the brain showed extensive meningeal enhancement with the involvement of the right trigeminal and abducens nerve along with thick enhancement along the right pons and midbrain. MR arteriogram revealed a large filling defect within the cavernous sinus. Intraventricular gentamicin was administered via external ventricular drain (ie, ventriculostomy) every 24 hours for 14 days with continued treatment of intravenous ceftriaxone and metronidazole. The patient improved with complete resolution of her cavernous sinus meningitis on repeat brain imaging at 6 months posthospitalisation.

Orbital Complications of Rhinosinusitis in the Adult Population: Analysis of Cases Presenting to a Tertiary Medical Center Over a 13-Year Period.

BACKGROUND: Orbital complications of rhinosinusitis in adults are scarcely discussed in the literature. OBJECTIVE: To review our experience with the management of orbital complications of rhinosinusitis in the adult patient population and identify key factors in the characteristics and management of these patients. DESIGN: Retrospective case series during the years 2004 to 2016 in a tertiary referral center including all patients with rhinosinusitis and orbital complications. MAIN OUTCOMES AND MEASURES: Severity of complications, risk factors, clinical, imaging and microbiological data, treatment outcomes. RESULTS: Seventy patients were identified. Median age at diagnosis was 38 years. In 57%, complications were associated with acute rhinosinusitis and in 43% with chronic rhinosinusitis, most of whom had a history of previous sinus surgery. Thirty-five percent of patients received antibiotics prior to admission. The majority of the previously operated patients (61%) had some form of orbital wall dehiscence noted on imaging. Preseptal cellulitis was the most common complication (61.5%) encountered, followed by orbital cellulitis (23%), sub-periosteal abscess (11.5%), orbital abscess (3%), and cavernous sinus thrombosis (1.5%). Gram-positive bacteria were more commonly isolated from acute rhinosinusitis patients and gram-negative bacteria from chronic rhinosinusitis (CRS) patients. Complete recovery was noted in all patients, of whom 85% were managed conservatively. All, but 1 patient, with an abscess or cavernous sinus thrombosis required surgical drainage. Older age was the only risk factor identified for severe complications. CONCLUSIONS: In contrast to the pediatric population, CRS is very common in adults with orbital complications of rhinosinusitis, with previous sinus surgery and orbital wall dehiscence being noticeably common. Older patients are at risk for more severe complications. Conservative treatment suffices in patients with preseptal and orbital cellulitis. In more advanced stages, surgical drainage is advocated with excellent results. Larger cohort studies are needed to further investigate this patient group.

Management of pediatric orbital cellulitis: A systematic review.

OBJECTIVES: Orbital complications account for 74-85% of all complications from acute sinusitis, more often affect the pediatric population, and can result in devastating consequences. Therefore these patients require prompt diagnosis and proper management. We review and summarize the current literature to determine the appropriate management of each stage of pediatric orbital cellulitis and offer a new comprehensive literature-based algorithm. METHODS: Data sources were PubMed/MEDLINE, and Google Scholar. Studies relevant to the management of each subcategory of the Chandler criteria in the pediatric population, limited to the period 1997 through Jan 2018, were compiled and interpreted. Seventy-one studies were reviewed in total. RESULTS: Pre-septal and post-septal cellulitis can generally be managed non-surgically, while orbital abscess and cavernous sinus thrombosis are managed surgically. For subperiosteal abscess, non-surgical medical management has been successful in certain patients. Results of the literature review were summarized, and subsequently developed into a comprehensive algorithm for management, including criteria for age, location, and volume of abscess on imaging. CONCLUSIONS: Orbital cellulitis, particularly subperiosteal abscesses, in children is not an absolute indication for immediate surgical intervention. Conservative measures can be safe and effective if appropriately used, depending on patient characteristics, clinical course, and imaging.

Intracranial complications of acute sinusitis in children: The role of endoscopic sinus surgery.

OBJECTIVE: To study the role of endoscopic sinus surgery (ESS) in the management of intracranial complications of children with acute rhinosinusitis METHODS: Retrospective chart review at a tertiary care pediatric hospital MAIN OUTCOMES: Demographics, intracranial complications, length of hospital stay (LOS), neurological sequelae, ESS, neurosurgical procedures RESULTS: Twenty-four children with a mean age (SD) of 12.9 years (+/-3.2) with an intracranial complication(s) of acute rhinosinusitis were identified between 2005-2016. A total of 22 were included and 15 (68%) of these were males. The most common complications were: subdural abscess (n=10), epidural abscess (n=10), meningitis (n=5), intraparenchymal abscess (n=5), and cavernous sinus thrombosis (n= 2). Neurologic symptoms included headache (n=12), hemiparesis (n=5) and aphasia (n=3). Average length of stay was 16 (+/- 9.2) days. Average follow up was 7 (+/-5.6) months. One patient had residual seizures and 1 had recurrent rhinosinusitis. Aphasia and hemiparesis resolved in all patients within 1 year. Nineteen (86%) patients had ESS within 4 days of admission. Fourteen patients (63%) had a neurosurgical procedure, 6 (27%) required more than 1 neurosurgical procedure. Six patients (27%) had concurrent neurosurgical drainage and ESS. Four patients (17%) had neurosurgical procedure followed by ESS and 3 patients (13%) were treated only by a neurosurgical procedure. Patients who underwent ESS prior to a neurosurgical procedure had significantly less risk of needing a neurosurgical intervention (OR = .02, p < .01). There was a significantly higher proportion of neurosurgical patients with positive Strep anginosus cultures compared to the ESS only group (85.7% vs 37.5%, p = .02). Studies with larger patient populations are needed to determine the role of ESS in the management of intracranial complications of children with acute rhinosinusitis. DISCUSSION: Early ESS may be associated with less need for neurosurgical procedures.

Transfemoral thrombectomy in the cavernous sinus and superior ophthalmic vein.

Cavernous sinus thrombosis (CST) is a rare condition that can cause death, neurologic disability, and visual loss. A pre-teen with septic CST leading to ocular hypertension and acute visual loss was treated at our institution with thrombectomy and thrombolysis of the cavernous sinuses and superior ophthalmic veins. Successful recanalization of the bilateral cavernous sinuses and superior ophthalmic veins was achieved in two separate procedures without complication. The patient showed immediate symptomatic relief. He was neurologically intact without visual deficits at the 2 month follow-up. This is the first report in the literature showing the feasibility of cavernous sinus thrombectomy using current devices and techniques. Early endovascular therapy may help preserve vision in patients with acute CST.

The dangers of the "Head Down" position in patients with untreated pituitary macroadenomas: case series and review of literature.

PURPOSE: Cavernous sinus syndrome is a rare phenomenon, characterized by simultaneous neuropathies of cranial nerves III-VI. Various pathological processes have been reported as precipitating etiologies, including infection, inflammation, vascular lesions, and neoplasms. PURPOSE: We report a unique case series of cavernous sinus syndrome attributable to prolonged Trendelenburg or prone positioning during non-cranial procedures and review the pertinent literature to enlighten on this rare but catastrophic phenomenon. METHODS: Retrospective case series. RESULTS: In the past year we encountered two patients who presented with acute cavernous sinus syndrome upon awakening from non-cranial operations. One patient underwent an extensive urologic resection of a bladder malignancy positioned in Trendelenburg for approximately 4 h. The second patient underwent a lumbar laminectomy and discectomy in prone position. Both patients were discovered to have infarcted large pituitary macroadenomas as the etiology of their acute ophthalmoplegias, and transnasal, transsphenoidal resection was performed acutely to decompress the cavernous sinus contents. Pathologic analysis of the resected specimens in each case confirmed necrotic, infarcted pituitary adenoma. Both patients made a complete recovery with no evidence of residual or recurrent tumor in short term follow-up. CONCLUSION: We report a brief case series of acute cavernous sinus syndrome resulting from dependent positioning during non-cranial operations in patients with pituitary macroadenoma. Although rare, this highlights a potential danger of "head down" positioning in patients with intracranial pathology-particularly in or around the sella and cavernous sinus. Despite multiple cranial neuropathies upon presentation, both patients made complete recovery following surgical decompression of the cavernous sinuses.

Spontaneous Bilateral Carotid-Cavernous Fistulas Secondary to Cavernous Sinus Thrombosis.

Bilateral carotid cavernous fistulas are rare entities that can cause debilitating symptoms and can lead to more severe consequences if left untreated. Therefore, the recognition and adequate treatment of these pathologies is very important. We present 2 cases of bilateral carotid cavernous fistulas that arose as a result of cavernous sinus thrombosis. We review the literature and discuss the pathophysiology, symptomatology, management, and treatment of bilateral carotid cavernous fistulas. Within our own cases, treatment of the patients was varied. The patient in case 1 was successfully treated with endovascular therapy after a failed trial of anticoagulation. The patient in case 2 demonstrated resolution of bilateral carotid cavernous fistulas after anticoagulation therapy. Case 2 highlights the fact that certain cases of bilateral carotid cavernous fistulas due to cavernous sinus thrombosis may benefit from extensive anticoagulation therapy. If anticoagulation therapy is unsuccessful, endovascular therapy may prove beneficial in resolving the fistulous shunt.

Transorbital superior ophthalmic vein sacrifice to preserve vision in ocular hypertension from aseptic cavernous sinus thrombosis.

Aseptic cavernous sinus thrombosis (CST) is rare and may clinically masquerade as a carotid cavernous fistula. Conventional management includes oral anticoagulation, but cases of ocular hypertension affecting vision may require more aggressive intervention. We report a case of a woman with spontaneous bilaterally occluded cavernous sinuses with elevated intraocular pressure (IOP), which resolved immediately following unilateral superior ophthalmic vein (SOV) sacrifice. She was subsequently placed on oral anticoagulants. By 4 months postoperatively her IOP was normalized and her vision had improved. Repeat angiography demonstrated stable venous filling, with some mild improvement of flow through the cavernous sinus. Coil-mediated sacrifice of the SOV might be an effective means to relieve ocular hypertension and preserve vision in the setting of aseptic CST.

Acute sphenoid sinusitis leading to contralateral cavernous sinus thrombosis: a case report.

INTRODUCTION: The objective of this article was to report a case of isolated, acute, right-sided sphenoid sinusitis that progressed to contralateral cavernous sinus thrombosis in an 18-year-old male patient. We describe the atypical presentation of this case and discuss the relevant anatomy, pathogenesis, presentation, diagnostic evaluation and treatment. CASE REPORT: A case report of sphenoid sinusitis leading to contralateral cavernous sinus thrombosis was reviewed and presented along with a comprehensive literature review of the relevant anatomy, pathophysiology, microbiology, diagnostic work-up and treatment options. CONCLUSION: Cavernous sinus thrombosis is a rare clinical entity in the antibiotic era. However, limited sphenoid sinusitis may progress to cavernous sinus thrombosis in spite of maximal medical treatment, as highlighted in this case report. The mainstay of treatment includes early diagnosis allowing aggressive intravenous antibiotics and appropriate surgical management.

Tumoral presentation of primary central nervous system lymphomatoid granulomatosis.

PURPOSE: Lymphomatoid granulomatosis (LYG) is an angiocentric Epstein-Barr virus (EBV) related B-cell proliferation associated with a reactive T-cell component with an uncertain malignant potential. LYG present at diagnosis as a mass lesion in the central nervous system (CNS) is rare, and only a few cases have been reported. In this article we present four cases of tumoral CNS-LYG and propose some guidelines for its management. METHODS: Clinical, pathological, imaging and laboratory information of four immunocompetent patients, all of them treated surgically, with a final diagnosis of LYG and presenting with an isolated intracranial tumoral mass is reviewed. RESULTS: Two parenchymal lesions were located in the cerebellum and temporal lobe, and the other two involved the cavernous sinus. At surgery they were avascular, hard, lard-like, necrotic and plastic well-defined lesions, with invasion of the leptomeninges and thrombosis of the small leptomeningeal arteries and veins. Intraoperative pathology excluded any tumor. Pathological studies showed a polymorphic and polyclonal infiltration around, in the wall and into the lumen of medium-sized cortical and leptomeningeal vessels causing their obstruction and tissular necrosis. EBV-infected cells were present. CONCLUSIONS: Making a preoperative diagnosis of CNS-LYG appearing initially as a tumoral mass is difficult because of the lack of pathognomonic clinical symptoms or imaging signs. Surgical management with radical resection of the mass is almost always followed by the long-term local control of the lesion, although the disease may have a disseminated, systemic or malignant evolution.

Bilateral septic cavernous sinus thrombosis following the masticator and parapharyngeal space infection from the odontogenic origin: a case report.

Neglect of odontogenic infections can have serious consequences. If they spread through fascial planes and intracranially they can cause an abscess, orbital cellulitis, and eventually cavernous sinus thrombosis. The authors report a case of rapid progressive bilateral orbital cellulitis and cavernous sinus thrombosis that originated from dental caries. Septic cavernous sinus thrombosis is a medical emergency. Early recognition and prompt treatments direct to the underlying sources of infection are crucial. Broad-spectrum intravenous antibiotics are the mainstay of treatment to reduce morbidity and mortality from this lethal condition. Management should be based on early diagnosis and prompt management with intravenous broad-spectrum antibiotics and surgical intervention.

Delayed cranial nerve palsy after coiling of carotid cavernous sinus aneurysms: case report.

OBJECTIVE: Detachable endovascular coils have become a common treatment strategy for carotid cavernous sinus aneurysms (CCAs), but previously unrecognized postprocedure complications may emerge as longer follow-up data are accumulated. In this report, the authors document the first known cases of delayed cranial neuropathy following CCA coiling in 3 patients, all of whom present at least a year postprocedure without aneurysm regrowth. The potential mechanisms underlying this syndrome are discussed as well as their implications on the selection and optimal endovascular management of CCA patients. CLINICAL PRESENTATION: Three previously healthy females aged 50, 60, and 62 underwent CCA coiling at our institution and subsequently developed ipsilateral cranial nerve palsies at 56, 28, and 14 months, respectively, post-procedure. At presentation, all 3 patients had a new, recurrent area of flow in their CCA without changes in aneurysm size. INTERVENTION: One patient declined further treatment. In the other 2 patients, a stent was placed across the aneurysm neck, and one patient underwent additional coiling. Unfortunately, all 3 patients remained symptomatic at their latest follow-up. CONCLUSION: Because of the intimate anatomic environment of the cavernous sinus, neural elements within it may be particularly susceptible to persistent mass or dynamic effects exacerbated by remnant or recurrent flow across the neck of a coiled aneurysm. These 3 cases prompted the authors to advocate for more aggressive efforts to achieve and maintain CCA occlusion. Furthermore, when such efforts are unsuccessful, consideration of traditional carotid occlusion strategies with or without bypass is warranted.

Suboccipital approach for primitive trigeminal artery obliteration associated with cavernous aneurysm.

OBJECTIVE: A 63-year-old woman presented with diplopia resulting from abducens paralysis. Examination revealed a giant cavernous aneurysm supplied by the internal carotid artery (ICA) and primitive trigeminal artery (PTA) via the vertebrobasilar system. METHODS: After evaluation of balloon test occlusion (BTO) at the distal side of the PTA origin, the aneurysm was treated with PTA obliteration through the suboccipital route in the lateral position followed by cervical carotid ligation with superficial temporal artery-to-middle cerebral artery anastomosis in the supine position. RESULTS: The aneurysm showed marked shrinkage after the surgery. CONCLUSION: PTA obliteration through the retrosigmoid opening is a therapeutic surgical option in a patient with a cavernous aneurysm supplied by the PTA.

Intracavernous sinus arachnoid cyst with optic neuropathy.

An 18-year-old man experienced progressive decreased visual acuity associated with a redness of the right eye for 1 month. An arachnoid cyst was identified within the right cavernous sinus and fenestration to the basal cistern was performed with the aid of a neuroendoscope. Visual acuity improved dramatically after the operation. Intracavernous sinus arachnoid cyst is a rare congenital intracranial lesion and surgical decompression may benefit symptomatic patients.