CASE REPORTS

Cavernous Sinus Thrombophlebitis: cose and protein levels, 10 white cells (9 mononuclear cells and 1 neutro­ Case Report phil), and negative gram stain and cul­ ture. The opening pressure was 22 cm of water. The peripheral white cell count was 13,000. The erythrocyte sed­ Timothy C. Kriss, M .D ., Vesna M artich Kriss, M .D ., imentation rate was 82. CSF, blood, urine, and sputum cultures were

Benjamin C. Warf, M.D. Downloaded from https://academic.oup.com/neurosurgery/article/39/2/385/2884550 by guest on 29 September 2021 negative. Departments of Surgery (Division of Neurosurgery) (TCK, BCW), Radiology (VMK), and Magnetic resonance imaging (MRI) Pediatrics (VMK), University of Kentucky Medical Center, Lexington, Kentucky revealed enlargement and abnormal en­ hancement of the left cavernous sinus, with enhancement and increased T2 sig­ OBJECTIVE AND IMPORTANCE: Cavernous sinus thrombophlebitis is a rare, nal extending posteriorly to the petrous apex and clivus. The sphenoid sinus dangerous, and historically difficult condition to diagnose and treat. Knowl­ was opacified. The intracavernous left edge of the imaging findings and the importance of early diagnosis and internal carotid artery was markedly treatment are emphasized. narrowed. Figure 1, A through D, shows CLINICAL PRESENTATION: We present a case of cavernous sinus thrombo­ the results of the MRI performed before phlebitis caused by sphenoid sinusitis. Previously undescribed magnetic treatment. resonance imaging findings of cavernous sinus thrombophlebitis include Intravenous broad-spectrum antibiot­ enlargement of the cavernous sinus, abnormal enhancement and increased ics (nafcillin, cefotaxime, and metroni­ T2 signal of the petrous apex and clivus, and marked narrowing of the dazole) were started immediately. En­ cavernous portion of the internal carotid artery. Resolution of cavernous doscopic left sphenoidotomy with sinus sinus thrombophlebitis is also documented by magnetic resonance imaging. drainage and ethmoidectomy were per­ INTERVENTION: The anatomy of the cavernous sinus dictates the natural formed. Fluid but no pus was obtained from the sphenoid sinus. Gram stain history and diagnosis of cavernous sinus thrombophlebitis. We review the and culture from the sphenoid sinus did literature regarding the clinical diagnosis, differential diagnosis, and treat­ not identify an organism. A cell count ment of cavernous sinus thrombophlebitis. was not obtained. CONCLUSION: We emphasize the importance of a high index of suspicion, The patient rapidly improved. MRI the potentially rapid and fatal course of the disease process, and the subse­ performed 1 week later demonstrated quent need for antibiotic therapy and selective surgery. (Neurosurgery 39: dramatic reversal of the previous mag­ 385-389, 1996) netic resonance (MR) findings: marked increase in the caliber of the left internal Key words: Cavernous sinus, Sinus thrombosis, Thrombophlebitis carotid artery with decreased abnormal enhancement of the clivus, petrous n the preantibiotic era, septic inflamma­ ache (behind her left eye) and diplopia apex, and cavernous sinus regions. F ig ­ tion/ thrombosis of the cavernous sinus for 2 weeks. She also had associated u re 2, A through C, shows the results of was uniformly fatal. In 1936, Grove (11) nausea, malaise, fatigue, and occasional the MRI examination after sphenoi­ reviewedI >400 cases with an estimated vomiting for 2 weeks, with 3 days of dotomy and antibiotic treatment. The 100% mortality. The vast majority of cases persistent low-grade fever. Her history patient completed a 6-week course of came from infections of the middle one- was significant for a recurrent sinus in­ intravenous antibiotics at home, with third of the face (7, 11, 26, 27, 30). In the fection treated with over-the-counter complete resolution of the sixth nerve postantibiotic era, morbidity and mortal­ medications (first treated 6 weeks before palsy, headache, and fever. ity rates remain high; 20 to 34% of patients admission and then again at 3 weeks still die, and >50% will suffer permanent before admission). neurological morbidity, usually a persis­ A neurological examination re­ DISCUSSION vealed a left sixth nerve palsy. A gen­ tent cranial nerve palsy, visual field defi­ Anatomy cit, or even blindness (7,18, 20, 21, 26, 27). eral physical examination revealed nothing remarkable, with the excep­ The diagnosis, pathophysiology, and tion of an oral temperature of 101°F; natural history of cavernous sinus CASE REPORT no meningismus was present. Cere­ thrombophlebitis are dictated by the An 8-year-old female patient pre­ brospinal fluid (CSF) from a lumbar anatomy of the cavernous sinus. The sented with slowly progressive head­ puncture demonstrated normal glu­ Vlth cranial nerve is the only cranial

Neurosurgery, Vol. 39, No. 2, August 1996 385 386 Kriss et al.

difficult to diagnose (7, 16, 18, 20,25,' 29). Patients with isolated sphenoid nusitis will usually have headaches ar low-grade fevers. With subsequent ca ernous sinus involvement, half of t patients will develop meningisnu which can easily distract the phvsici from diagnosing the true source oft problem, the sphenoid sinusitis. B cause of these difficulties, the diagno- of cavernous sinus thrombophlebitis

often delayed, with ominous ramificDownloaded from https://academic.oup.com/neurosurgery/article/39/2/385/2884550 by guest on 29 September 2021 tions (7, 16, 18, 20, 25). A high index suspicion is critical for both spheno sinusitis and cavernous sinus thromb phlebitis (6, 16, 18, 20, 25). Other cau- of cavernous sinus thrombophlebitis i elude infections of the middle third the face and dental infections (by way emissary veins and the pterygoid pie us), although the latter is much les common (7, 27). The differential diagnosis of caven ous sinus thrombophlebitis focuses o other causes of periorbital edema i multiple cranial nerve palsies. Otherir flammatory orbital conditions includ orbital cellulitis, infraorbital abscess, a! lergic blepharitis, ocular migraine,anc Tolosa-Hunt syndrome (14). In pa­ tients with cranial nerve signs, the di: ferential diagnosis would favot FIG U RE 1. A, Tl-weighted, contrast-enhanced coronal MR image demonstrating trauma, internal carotid artery aneu abnormal enhancement of the cavernous sinus with marked narrowing of the cali­ rysm, carotid-cavernous fistula, tumoi ber of the cavernous portion of the left internal carotid artery (arrow). Note the (meningioma or nasopharyngeal), pi­ sphenoid sinusitis. Axial MR images without (B) and with (C) contrast enhance­ tuitary abscess, mucormycosis, or as­ ment, showing the abnormal enhancement of the cavernous sinus, clivus, and pergillosis of the sphenoid sinus. petrous apex (arrows). T2-weighted axial image (D) demonstrating increased signal of the clivus and petrous apex (arrow), as well as the sphenoid sinusitis (arrowhead). Diagnosis The diagnosis of cavernous sinus nerve that actually runs within the cav­ nous connections, the cavernous sinus is thrombophlebitis is clinical and can b ernous sinus; all other cranial nerves of uniquely positioned to transmit infec­ predicted from the anatomy (2, 4,6. the cavernous sinus (III, IV, V„ V2) run tion or thrombus from the face or sphe­ 13, 17, 25-27). Obstruction of the supe within the lateral dural wall of the sinus. noid sinus into the dural sinuses and rior orbital vein causes proptosis, die- The intracavernous portion of the inter­ central nervous system. Cranial nerves mosis, and orbital edema. These Iocs nal carotid artery (along with its accom­ III, IV, VI, Vv and V2 and the intracav­ eye signs and symptoms, in conjunct^ panying sympathetic plexus) is the only ernous internal carotid artery (and its with a Illrd, IVth, or Vlth cranial nerve other structure within the sinus (12, 15). sympathetic plexus) are directly ex­ palsy, suggest the diagnosis of cavern­ Each cavernous sinus receives blood posed to any inflammatory process in ous sinus thrombophlebitis (2,4,6,7, U from the orbit via the superior and infe­ the cavernous sinus. The nearby optic 25-27). Progression from unilateral or rior ophthalmic veins. There are no nerve and V3 are also at risk. bital signs to bilateral involvement is valves in any of the dural sinuses (7, 26), ominous indicator that is essentially p-1 which has important implications for Pathogenesis thognomonic (25). the spread of infection or thrombus. Be­ Headache, often from s p h e n o i d sinU' cause of its central location adjacent to Sphenoid sinusitis is the most com­ itis, is present in >90% of the p a tie n ts (- the thin-walled sphenoid sinus (15) and mon modern cause of cavernous sinus 7, 17, 18, 20, 25-27). It typically has • its myriad potentially bidirectional ve­ thrombophlebitis, but it is notoriously unilateral and retro-orbital or front

Neurosurgery, Vol. 39, No. 2, August 1996 Cavernous Sinus Thrombophlebitis 387

phy (CT) is the test of choice to diagnose sphenoid sinusitis (6, 20, 25, 28). MRI is the best imaging method for suspected cavernous sinus thrombo­ phlebitis (5, 7, 17, 24). The signal inten­ sities of the sinus can vary significantly as a result of infection, inflammation, and clot evolution (13, 19, 24). Inflamed meninges may worsen (13). Sphenoid sinus opacification with increased T2 signal is consistent with sphenoid sinus­ Downloaded from https://academic.oup.com/neurosurgery/article/39/2/385/2884550 by guest on 29 September 2021 itis. The cavernous sinus may be en­ larged, and the absence of flow void in the sinus suggests thrombosis (13, 19, 24). MRI in our case demonstrated para- meningeal enhancement and increased T2 signal along the clivus and petrous apex. This parameningeal enhance­ FIG U RE 2. A, follow-up MR scan after 1 ment, however, can also be seen in week of treatment (sphenoidotomy and other subacute and chronic inflamma­ antibiotics), showing normal caliber of tory processes. The dramatic decrease the cavernous portion of the left carotid artery (arrow) on the contrast-enhanced in the diameter of the intracavernous T1-weighted coronal image. Axial MR internal carotid artery was also docu­ images without (B) and with (C) contrast mented by MRI, as was its subsequent enhancement, demonstrating decreased resolution. abnormal enhancement of the cavernous If MRI is unavailable, CT remains an g sinus, clivus, and petrous apex after excellent method for the examination of » treatment. cavernous sinus thrombophlebitis. CT enhanced with contrast will show mul­ J temporal orientation. Pain or paresthe­ sory deficits in V-, and V2 (25, 27). tiple filling defects from clot formation sias in the V-j/V2 distribution occur less Patients with advanced disease will within the sinus (1, 6). If the sinus is commonly (18, 27). Fever is universally appear toxic or lethargic (6, 18). completely thrombosed, there will be present (2, 7, 17, 18, 27). Diplopia can All patients suspected of having cav­ complete lack of enhancement (1, 20, s precede other symptoms (4, 25, 26). Fifty ernous sinus thrombophlebitis should 23). The cavernous sinus may be en­ percent of patients will have signs and undergo lumbar puncture and thorough larged or asymmetric, with enhancing j symptoms of meningitis by the time examination by an otolaryngologist (2, inflamed meninges (1, 13). Occasionally, medical help is sought (7, 18, 26-28). 7, 16, 20, 27-29). In diabetic patients and dilated infraorbital veins, in particular Patients can present with lethargy and those who fail to respond to antibiotics, the superior ophthalmic vein, will be mucormycosis must be ruled out (27). coma late in the course (18, 27). visible (6). CSF studies usually show inflammation, Physical examination reveals signs of Cerebral angiography is generally not although the cultures are negative. superior orbital vein occlusion, includ­ helpful in the diagnosis of cavernous ing chemosis, proptosis, and orbital Blood cultures are positive in many sinus thrombophlebitis. Even with good edema (25). Extraocular muscle palsies cases (18, 27, 28). angiographic technique in normal pa­ will be present, and the sixth nerve is tients, the cavernous sinus is visualized most commonly affected (2, 7, 25, 26). Imaging only 42% of the time (1). The cavernous Less often, Horner's syndrome or a portion of the internal carotid artery is dilated/sluggishly reactive pupil will Properly obtained sinus x-rays are sometimes narrowed or obstructed (6). be present (7, 26). Half of the patients sensitive for sphenoid sinusitis (show­ Venous phase films may show poor fill­ will have meningismus and inflamma­ ing opacification, air-fluid level, or scle­ ing of the cavernous sinus (25). Orbital tory CSF, although cultures are rarely rosis/erosion of the sinus walls). A lat­ positive (7, 18, 26, 27). Fever is a con­ eral and submental vertex view must be venography can effectively diagnose stant finding (2, 7, 18). One-third will included to optimally visualize the cavernous sinus thrombosis, but it is have papilledema (26, 27). One of five sphenoid sinus (4, 7, 16, 26, 28). It is rarely used (8, 25, 26). It is important to patients will have a decrease in visual important to note that plain films, al­ remember that this entity remains a clin­ acuity or field cut; —10% will experi­ though sensitive, can reveal normal re­ ical diagnosis; MRI, CT, plain film radi­ ence permanent blindness (26). Care­ sults in patients with sphenoid sinusitis ology, and angiography are only confir­ ful testing will frequently elicit sen­ (18, 20). Therefore, computed tomogra­ matory methods.

Neurosurgery, Vol. 39, No. 2, August 1996 388 Kriss et al.

Treatment thrombophlebitis can be fatal (6) or re­ tracerebral hemorrhage in patients sult in serious complications. These ceiving anticoagulants for cavernous Early recognition and treatment of complications, largely collected from nus thrombophlebitis (22, 26). cavernous sinus thrombophlebitis are case reports, include meningitis (7, 18, There is no solid evidence that st crucial (4, 6,18, 26). A delay in treatment 20, 26), infarction of the cerebrum, brain roids are beneficial in the treatment resulted in 100% morbidity in one large stem, or pituitary gland (13, 20), septic cavernous sinus thrombophlebitis. [ series, and delays can be fatal (18, 25, emboli, thrombosis of the internal ca­ fective corticosteroid use is limited 29). Immediate and appropriately cho­ rotid artery (1), brain abscess or empy­ cranial nerve dysfunctions caused bv sen broad-spectrum antibiotics are the ema (6, 31), cortical vein thrombosis (18, flammation and the prevention of Ac mainstay of therapy. Staphylococcus au­ 20), pituitary dysfunction, blindness, disonian crisis in patients with sever reus is the pathogen in one-half to two- and cranial nerve palsies (16, 20). The associated pituitary dysfunction (7, ]' thirds of all cases of cavernous sinus true incidence of these serious sequelae 26). The literature describes two casesDownloaded from https://academic.oup.com/neurosurgery/article/39/2/385/2884550 by guest on 29 September 2021 thrombophlebitis (3, 20, 26-28). Strepto­ is unknown; they are documented which optic nerve and orbital inflamm cocci (particularly Pneumococcus) are the largely as case reports or components of tion were resistant to antibiotics buth, next most common organisms (7, 18, 20, small series of cavernous sinus throm­ dramatic responses to steroids (9, 7 26, 28). Gram-negative rods and anaer­ bophlebitis. There is no evidence that 26). There is not a single case in tl obes combined are found in —10 to 20% persistent deficits are aided by surgical literature in which steroids were the p’ of cases (2, 7, 18, 26, 27). Thus, immedi­ drainage; too few cases exist in the lit­ mary successful mode of treatmen ate empiric antibiotic coverage must in­ erature from which to draw any mean­ Given the importance of the immun clude gram-positive, gram-negative, ingful conclusions. response in combating this rapidly pr and anaerobic coverage. Lactamase- Anticoagulant therapy for cavernous gressive infection, steroids are general! resistant penicillins (such as methicillin sinus thrombophlebitis is controversial not recommended. or nafcillin) must be included for proper (17, 25, 26). Because the condition is staphylococcal coverage. Later in the rare, the only data available are retro­ course of treatment, antibiotics can be spective compilations of case reports CONCLUSION narrowed according to cultures and with varying treatments and patient Cavernous sinus thrombophlebitis sensitivities. populations (17, 26). One such study at­ a rare but dangerous entity that can b Sphenoid sinusitis in the context of tributed a twofold reduction in morbid­ difficult to diagnose. Nonetheless, earl cavernous sinus thrombophlebitis may ity to "early" administration of heparin diagnosis and treatment are crucial require sphenoidotomy and drainage (4, (within 7 d of hospitalization). Eighty- Broad-spectrum antibiotics should h 7, 10, 16, 18, 20, 26). In the series pre­ two patients treated with antibiotics rapidly initiated, and surgical drainagt sented by Lew et al. (18) of 15 cases of alone had a 61% neurological morbidity of a likely source of infection shouK "acute" sphenoid sinusitis (symptoms rate versus 31% in 16 patients treated be considered. Morbidity and mortalit for <1 mo, similar to our case), all nine with antibiotics and heparin within 7 remain high even with approprialt patients with delays in diagnosis or days. These same authors saw no statis­ therapy; delay in treatment can I1 treatment had serious complications or tical change in mortality rates (17). A catastrophic. died. Of the 11 survivors in this series, 8 second, similar review of cases pre­ required surgical drainage for cure. All sented the opposite conclusion. These Received, August 28, 1995. four of the patients in this series who latter authors compiled 86 cases of cav­ Accepted, February 26, 1996. died had sphenoid sinusitis and basilar ernous sinus thrombophlebitis, of which Reprint requests: Vesna Martich Kriss, MI meningitis at autopsy; three of the four 32% were treated with heparin; patients Department of Diagnostic Radiology, AIK patients also had cavernous sinus treated with anticoagulants experienced B. Chandler Medical Center, University 1 thrombophlebitis at autopsy. Interest­ a 14% mortality rate versus 36% in the Kentucky, 800 Rose Street, Lexington, 1 ingly, in the study by Lew et al. (18), patients who had not received heparin 40536-0084. only 2 of 15 patients had predisposing (26). No scientific consensus regarding factors such as diabetes. 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Neurosurgery, Vol. 39, No. 2, August 1996 Downloaded from https://academic.oup.com/neurosurgery/article/39/2/385/2884550 by guest on 29 September 2021 389 Sean F. Mullan Chicago, Illinois Washington, District of Columbia William Monacci Laligam N. Sekhar Cavernous sinus thrombophlebitis is In this report, Kriss et al. reemphasize Magnetic resonance imaging findings early enough. Sphenoidotomy in stance this in­ did not revealspecific antibiotic medication pus, and efficient but becausedrainage of localized pus are the essential if doubt exists, it is better to undertake tivity and drainage, than to attempt the components of management, I agree that aspiration early, to obtain bacterial sensi­ procedure as the condition deteriorates. the anecdotal rather nature than of the the literature, but statistical I support the prompt treatment of sinus infections the diagnosis, differential diagnosis, The use of somement, elements e.g., anticoagulants of may manage­ and remain steroids, debatable, in keeping with opinion of the authors. a serious condition thatdeath canof the leadpatient if to it is notthe diagnosedpromptly and treated tunately, adequately. the For­ incidence of this serious and treatment of resonance this imaging entity. findings Magneticsized are empha­ that reported. have not been previously reported here are not specific for cav­ lesions involving the cavernous sinus. acute clinical syndrome and the radio- condition has decreased with because antibiotics. of ernous sinus thrombophlebitis,have seen butsimilar we findingsof in subacute a number and chronic inflammatory Obviously, the diagnosis has to afterbe made considering the combination of the graphic findings. Cavernous Sinus Thrombophlebitis Vol. 39, No. 2, August 1996 ANNOUNCEMENT teremia and apparent thrombosis of the cav­ ernous sinuses2139-2141, with 1937. recovery. JAMA 109: Medicine 65:82-106, 1986. gol 70:263-267, 1961. Otol 103:526-527, 1989. thies in sinus disease. Laryngoscope 87:357- Nyhan WL: Cavernous sinus thrombosis. West Arch Otolaryngol 51:917-924, 1950. tomographic findings in nouscerebral thrombosis. sinus and Radiology ve­ 140:391-398, 1981. scope 93:797-800, 1983. tic thrombosis of the dural venous sinuses. sphenoiditis: A diagnostic problem. J Laryngol of cavernous sinus thrombosis: Review of 878 bral dural sinus Tomogr thrombosis. 10:889-891, J Comput 1986. Assist cases in the literature. Ann Otol Rhinol Laryn­ 363, 1977. J Med 133:44-48, 1980. sinus thrombophlebitis:J Indian A review Med of Assoc 35 90:290-292, cases. 1992. bitis secondary to sphenoid sinusitis. Laryngo­ A review of the current literature doc­ Theirs was not the most fulminating case, but it illustrates that adequate treat­ ment achieves a total cure, if undertaken problem seems to be a tion lack of of the anticipa­ entity, with a consequential treatment. The authors to alert the the ongoing reader threatsuccessful and management describe of the their patient. COMMENTS uments that cavernoussis, although sinus now thrombo­ a very stillrare disease,accompanied is by disturbingmorbidity rates of and analysis mortality. would suggest A that detailed the main delay in diagnosis and in initiating 28. Urquhart AC, Fung G, McIntosh WA: Isolated 29. Weisberger EC, Dedo HH: Cranial neuropa­30. Yaringtron CT Jr: The prognosis and treatment 31. Zahller M, Spector RH, Skoglund RR, Digby D, 22. Pirkey P: Thrombosis of the 23. cavernous Rao KCVG, sinus. Knipp HC, Wagner EJ: Computed 24. Snyder TC, Sachdev HS: MR imaging of cere­ 25. Sofferman RA: Cavernous sinus thrombophle­ 26. Southwick FS, Richardson EP, Swartz MN: Sep­ 27. Thatai D, Chandy L, Dhar KL: Septic cavernous 21. MacNeal WJ, Cavallo ME: Streptococcic bac­ Neurosurgery, World Federation of Neurosurgical Societies Meeting Australia will be the site of their Xllth International Congress, to be held in 2001. The World Federation of Neurosurgical Societies has announced that Sydney,

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