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Four cases of lateral sinus thrombosis have been treated at Notre-Dame Hospital, Montreal, since 1960. A review of the literature of this pathology is reported, and two cases treated in the past three months are presented.
A 7 year-old boy with unilateral septic cavernous sinus thrombosis following a pyoderma in the eyebrow is described. Problems in diagnosis and the role of magnetic resonance imaging (MRI) in the management are highlighted. Patient recovered with mild residual sequelae. The unique feature of this case was absence of chemosis and non-toxic presentation of the patient.
OBJECTIVES: To evaluate the clinical course and identify the causative organisms of acute mastoiditis in a community where most of the patients who develop acute otitis media are treated with antibiotics. METHODS: A multicenter retrospective review of a series of 223 consecutive cases of acute mastoiditis. SETTING: Nine secondary or tertiary academic or non-academic referral centers. RESULTS: Prior to the diagnosis of acute mastoiditis, 121 of the patients (54.3%) had been receiving oral antibiotic treatment for acute otitis media for periods ranging from 1 to 21 days (mean 5.3 days). Samples for bacterial culture were obtained from 152 patients. Cultures were negative in 60 patients. The organisms isolated in the 92 positive cultures were: Streptococcus pneumoniae (15 patients), Streptococcus pyogenes (14 patients), Staphylococcus aureus (13 patients), Staphylococcus coagulase negative (three patients), Pseudomonas aeruginosa (eight patients), Haemophilus influenzae (four patients), Proteus mirabilis (two patients), Escherichia coli (two patients), Klebsiella pneumoniae (one patient), Enterobacter (one patient), Acinetobacter (one patient), anaerobic gram-negative bacilli (one patient), and fungi (two patients). Ten patients had mixed flora. Sixteen patients presented with complications (cerebellar abscess, perisinus empyema, subdural abscess or empyema, extradural abscess, cavernous sinus thrombosis, lateral sinus thrombosis, bacterial meningitis, labyrinthitis, petrositis, or facial nerve palsy). CONCLUSIONS: Antibiotic treatment cannot be considered an absolute safeguard against the development of acute mastoiditis. Early myringotomy for acute otitis media seems to decrease the incidence of complications. The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media. Intracranial complications in acute mastoiditis are not rare. Because of the diversity of causative organisms in acute mastoiditis and the growing resistance of bacteria to the various antibiotics, all means to obtain a sample for culture prior to antibiotic treatment, including general anesthesia.
OBJECTIVE: Analysis of signs, symptoms, course and treatment of patients with cerebral venous and sinus thrombosis (CVST). DESIGN: Retrospective study. SETTING: Neurological departments of Dutch teaching hospitals. METHOD: Analysis of data of patients admitted to the neurological wards of nine teaching hospitals, diagnosed from 1970 to 1990. All patients with a clinical diagnosis of CVST, confirmed by X-ray angiography, magnetic resonance imaging, surgery or autopsy were included. Patients with cavernous sinus thrombosis were excluded. The clinical condition of patients after 3 months was scored on a 4-point scale. RESULTS: Of 93 patients 62 fulfilled the inclusion criteria. Three months after the diagnosis 41 patients (66%) had recovered, 10 patients (16%) were seriously disabled, 11 patients (18%) had died. Factors associated with a poor outcome were coma (relative risk 3.5) and hemiparesis (relative risk 2.3) at the time of diagnosis. Signs of cerebral haemorrhage or infarction (by computed X-ray tomography) were associated with disability or death. Anticoagulant treatment was not significantly associated with a better or poorer outcome in these patients. CONCLUSION: This study confirms the variations in causes, clinical presentation, natural history, and treatment of CVST. No conclusion could be drawn about the effect of anticoagulant treatment.
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Cerebral sinus and venous thrombosis were diagnosed by computed tomography (CT) and subsequently confirmed by other studies in eleven patients. CT revealed normal or small ventricles, hemorrhages, low-density areas, and increased density of dural sinuses and tentorium. CT in combination with appropriate angiographic studies is necessary for diagnosis and confirmation of sinus and venous thrombosis. Proper use of CT can result in decreased morbidity and mortality associated with this condition.
OBJECTIVE: Cerebral sinus venous thrombosis (cerebral SVT) is rare in children. Information on clinical characteristics, radiological findings and outcome is emerging. METHODS: Cases of cerebral SVT diagnosed between 1995 and 2001 were identified by a computer-assisted search using International Classification of Disease codes. Medical records were reviewed to collect information on clinical presentation, investigations, treatment and outcome. RESULTS: Sixteen cases of cerebral SVT were identified. All cases presented in association with head and neck pathology. The majority of cases presented with symptoms of raised intracranial pressure and focal neurological signs. Magnetic resonance imaging identified all cases of cerebral SVT whilst CT scanning failed to demonstrate the diagnosis in two cases. Management with anticoagulation was associated with radiological resolution of the thrombosis and normal neurological outcome. Long-term follow up demonstrated neurological deficits in greater than 40% of patients. CONCLUSION: Cerebral SVT in children is associated with significant residual neurological morbidity. Prospective studies to identify predictors of outcome and effective management interventions are required.
Cerebral sinus and venous thrombosis account for less than 1% of all strokes, but diagnosis is often overlooked due to the variety of clinical syndromes and the variable clinical course. Underlying conditions do not significantly differ from those seen in extracerebral venous thrombosis. Conventional intra-arterial four-vessel angiography was long the only diagnostic technique for confirming diagnosis, but nowadays magnetic resonance imaging and angiography are sufficient in many cases. Full-dose heparin treatment is the therapy of choice and is performed even if an hemorrhagic infarct already exists. If treatment is initiated early, the mortality rate of nonseptic cerebral sinus and venous thrombosis is less than 10%. According to general rules of postthrombotic treatment, patients should be treated with oral anticoagulants for a period of at least three months.
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BACKGROUND AND PURPOSE: The pathophysiology of sinus vein thrombosis (SVT) is still controversial in patients and experimental animals, the microcirculatory alterations in particular. This study was designed to develop a new sinus vein thrombosis model and to further elucidate pathophysiological events such as the relationship between local and regional cerebral blood flow and haemoglobin oxygen saturation (HbSO2), changes of the microvasculature, leukocyte behaviour and brain tissue damage. METHODS: In a first experimental series, animals were divided into two groups which resulted from different procedures of inducing SVT. In the SSS middle occlusion group (SMO group), SVT was induced by the ligation of the superior sagittal sinus right in the middle between the bregma and the confluence sinum. In the SSS posterior occlusion group (SPO group) the ligation was performed close to the confluence sinum. Regional cerebral blood flow (rCBF) was assessed at 36 identical locations by laser Doppler flowmetry together with regional haemoglobin oxygen saturation (HbSO2). In a second series of experiments SVT was induced by ligation of the SSS close to the confluence sinum (SVT group) to study effects on the cortical microcirculation. A sham operation was performed in six animals (sham group). In both groups, an intravital microscopic double tracing technique was utilised for evaluating microvessel structures and leukocyte behaviour. The images were recorded on videotape for evaluating alterations of microvessel (venules, arterioles and capillaries) diameters and numbers of leukocyte rollers and stickers by a digital video analyser. Animals were sacrificed for histological evaluation after 5 days. RESULTS: The posterior sinus ligation caused a significant decrease of rCBF and HbSO2 and brain tissue damage which was not seen in the SMO group. Alteration of rCBF and HbSO2 were positively correlated with infarct size in the SPO group only, where venous infarction was easily reproduced. Therefore, it is suggested that this model is suitable for studying SVT in Mongolian gerbils. Intravital microscopy of the cortical microcirculation revealed no significant changes of vessels diameter in the sham group, whereas a significant dilation of veins and capillaries was seen in the SVT group. Numbers of leukocyte rollers and stickers were positively correlated with infarct size. CONCLUSION: Microcirculatory alterations and brain tissue damage from SVT in the Mongolian gerbil depend on the SSS occlusion site. The newly established mongolian gerbil sinus-vein thrombosis model has advantages compared to previously reported sinus-vein thrombosis models such as easy handling, easy technique, highly reproducibility, and good observation of microcirculatory event. The model allows for studies of cerebral low-flow conditions such as expected to occur in an ischaemic penumbra zone.
The authors report a case of cavernous sinus thrombosis of paranasal sinus origin. Such complication developed in a case of chronic exacerbated sinusitis and blockade of sinus orifices by polyps. Timely and effective surgical intervention combined with medical treatment achieved complete remission even of the complications of cavernous sinus thrombosis.
OBJECTIVES: To familiarize the contemporary surgeon with the pathogenesis, diagnosis, and appropriate management of suppurative intracranial complications of sinusitis. STUDY DESIGN: Retrospective chart review. METHODS: All patients admitted to the University of Virginia Health Sciences Center with a diagnosis of intracranial suppuration between 1992 and 1997 were reviewed. RESULTS: One hundred seventy-six cases were identified, of which 15 patients had 22 suppurative intracranial complications of sinusitis. These were epidural abscess (23%), subdural empyema (18%), meningitis (18%), cerebral abscess (14%), superior sagittal sinus thrombosis (9%), cavernous sinus thrombosis (9%), and osteomyelitis (9%). CONCLUSIONS: The diagnosis of suppurative intracranial complications of sinusitis requires a high index of suspicion and confirmation by imaging. Central to the success of treatment is the management of the primary source of sepsis within the paranasal sinuses in combination with neurosurgical drainage and intravenous antibiotics. This approach has resulted in a mortality rate of 7% and morbidity of 13%, which compare favorably with previous series.
The pregnancy increases the risk of cardiovascular ischemic events, The longitudinal sinus thrombosis is very rare, but the incidence increases during pregnancy and puerperium. The mortality rates range from 25% to 50%. This report consists of a case which was studied and managed at the Military Central Hospital. It occurred on the 12th day post C-S. The diagnostic was confirmed by MRI. The treatment consisted of rest and heparin with a successful development. Our findings agreed with the studies reported at the literature that suggested a beneficial effect with the heparin's use, lowering drastically the mortality rates. Some still oppose to its use because of the risk of an intracranial hemorrhage.
Venous thrombophilia is the result of clotting changes namely of a hypercoagulable state together with blood flow and vessel wall changes. There is no need for all these components to be present in order for thrombosis to occur. As the matter of fact, thrombosis may occur even if only one of these conditions is present. In clinical practice a combination of factors is usualy seen. In comparison with arterial thrombophilia, clotting changes and blood flow seen to play a major role in venous thrombosis. Venous thrombophilia may remain asynptomatic or may result in a series of clinical syndromes. The commonest of these are: 1. Superficial vein thrombosis, 2. Deep vein thrombosis of legs, 3. Deep vein thrombosis of arms, 4. Caval veins thrombosis, 5. Portal vein thrombosis, 6. Hepatic veins thrombosis, 7. Renal vein thrombosis, 8. Cerebral sinuses thrombosis, 9. Right heart thrombosis, 10. Miscellaneous (ovarian, adrenal veins thrombosis, etc.). Since the first two are widely and easily recognized, these is no need for an extensive discussion. Deep vein thromboses of upper limbs are not as frequent as those of lower limbs or of superficial phlebitis but they can still be recognized on clinical grounds and non invasive techniques. The remaining 7 syndromes are less common and therefore less frequently suspected and recognized. Of particular interest, among these less common manifestations of venous thrombophilia are hepatic vein and renal vein thrombosis. Hepatic veins thrombosis, sometimes part of inferior vena cava thrombosis is most frequently due to an isolated occlusion of hepatic veins thereby causing a form of venocclusive disease. Occasionally diagnosis may be difficult because of slow onset of symptoms (hepatomegaly, right flank pain, fever, ascites etc.). The same is true for renal vein thrombosis which may also be of difficult diagnosis since it causes proteinuria and flank pain. The proteinuria is often interpreted as due to a nephrotic syndrome which, incidentally, may cause by its turn renal vein thrombosis. Portal vein thrombosis and cerebral sinuses thrombosis on the contrary are more easily suspected because of ascites, adominal pain, jaundice or headache, eye proptosis, vomiting. Right heart thrombosis should be suspected in cases of recurrent pulmonary embolization. Ovarian or adrenal veins thrombosis are rare. The competent physician should always consider, given certain congenital or acquired conditions, the possibility to be facing a special form of venous thrombosis or a venous thrombosis in unusual sites. An early diagnosis, as often in medicine, is of paramount importance for a prompt treatment and a satisfactory outcome.
A 34-year-old woman was admitted on the 10th day post partum complaining of loss of strength in the left arm and headache. The next day she started having seizures. Although the clinical picture suggested sinus thrombosis, initially a CT scan showed no abnormalities. The diagnosis of sinus sagittalis superior thrombosis was finally made by means of arteriography. The patient was treated successfully with anticoagulants and recovered without sequelae.
OBJECTIVE: The purpose of the study was to show equivalence or superiority of CT venography compared with the existing test of choice--MR venography--in the evaluation of dural sinus thrombosis and in the identification of cerebral veins and dural sinuses. MATERIALS AND METHODS: Twenty-four patients underwent both CT and MR venography of the intracranial venous circulation. Seventeen patients were examined for suspected dural sinus thrombosis. Four patients underwent projection venography to assess tumor invasion of a major dural sinus. The remaining three patients were examined for cavernous sinus thrombosis, arteriovenous malformation, and an elevated jugular bulb. Without knowledge of the patients' case histories, two radiologists evaluated each CT venogram and MR venogram. The radiologists then arrived at a consensus regarding the absence or presence of dural sinus thrombosis. Later, the radiologists conducted a second interpretation with knowledge of the patients' clinical histories during which time MR and CT venograms were compared with regard to the advantages and disadvantages of each imaging technique. In addition, the venograms were assessed for the presence of 12 different venous structure. Projection venograms were displayed using a maximum-intensity-projection (MIP) algorithm, and the individual source images were also evaluated. The CT venograms were also displayed using shell-MIP and integral display algorithms. RESULTS: Using MR venography, the two radiologists diagnosed dural sinus thrombosis in eight of the 17 patients with suspected dural sinus thrombosis. In these eight patients, the diagnosis was also made with CT venography. The diagnosis was confirmed by follow-up CT in four patients and by follow-up MR imaging in two patients. The MIP algorithm did not allow direct visualization of thrombus by either the CT or the MR imaging technique; however, the CT integral display algorithm enabled direct visualization of thrombus on the three-dimensional projection venograms. The systematic comparison of imaging techniques showed that CT venography reliably reveals all cerebral veins and sinuses when they are seen with MR venography. In addition, CT venography more frequently visualizes sinuses or smaller cerebral veins with low flow as compared with MR venography. CONCLUSION: Cerebral CT venography is superior to MR venography in the identification of cerebral veins and dural sinuses and is at least equivalent in the diagnosis of dural sinus thrombosis. CT venography is a viable alternative to MR venography in the examination of patients with suspected dural sinus thrombosis.
A 20-year-old Turkish patient presented with superior sagittal sinus thrombosis which led to the final diagnosis of Behçet's disease. The frequency of cerebral venous thrombosis is generally underestimated and may be the first clinical manifestation of Behçet's disease. Uveitis as a main diagnostic criterion of Behçet's disease may be absent, especially in young men. In cases of intracranial hypertension, cerebral venous thrombosis and Behçet's disease should be taken into consideration, especially in a high risk population from eastern Mediterranean countries and Japanese islands. Treatment with early anticoagulation in cerebral venous thrombosis, and corticosteroid-pulse therapy in active Behçet's disease, seems to be established today. As a basic therapy of Behçet's disease cyclosporin A and the classic immunosuppressive agents, especially azathioprine, are available. Clinical course and prognosis in cerebral venous thrombosis are generally both benign, provided that adequate management is started in time.
PURPOSE: We report on our first experience in imaging the cerebral veins and sinuses with CT angiography (CTA). MATERIAL AND METHODS: CTA was performed in 10 patients after bolus injection of contrast medium to rule out sinus thrombosis. RESULTS: In 8 of 10 patients thrombosis of cerebral venous sinuses was ruled out by CTA. Sinus thrombosis was diagnosed and confirmed in two patients. In 5 cases, diagnosis of CTA was confirmed by MRI and/or DSA, in 5 other cases by the clinical course. CTA results in detailed information about flow and anatomy of cerebral veins due to high intravascular contrast. CONCLUSIONS: CTA is a suitable noninvasive method to study cerebral veins as it is superior to conventional CT because of high resolution and intravascular contrast. To assess the sensitivity of CTA for diagnosis of venous sinus thrombosis a prospective study is needed.