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PubMed2004

Short-course therapy for acute sinusitis: how long is enough?

This review examines the issues surrounding short-course antibiotic therapy of acute sinusitis. Acute bacterial sinusitis is a common community-acquired infection defined as inflammation of one or more paranasal sinuses, most often the maxillary sinus. It is estimated that 0.5-5% of colds are complicated by acute sinusitis. Up to 1 in 20 upper respiratory tract infections is complicated by bacterial sinusitis, most often caused by Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Staphylococcus aureus. Early diagnosis and appropriate antibiotic therapy, in combination with agents that relieve nasal congestion, are important factors in preventing suppurative complications. Left untreated, it could lead to the development of chronic sinusitis or epidural or subdural empyema, brain abscess, or cavernosus sinus thrombosis. Isolation of the causal organism is often lacking in the community setting. Empiric antibiotic therapy should provide adequate coverage against the most important pathogens. Guidelines from different specialist societies based on current scientific knowledge are helpful in making the decision on which drug to use. Recommendations for duration of treatment of acute sinusitis are inconsistent between different guidelines but usually a 10- to 14-day treatment course is recommended.Recognition that the 10- to 14-day duration of therapy is not derived from a strong scientific or medical rationale has led some clinicians to call for shortening the duration of antibiotic therapy for patients with upper respiratory tract infections. Accumulating evidence suggests that short-course (< or =5 days) antibiotic therapy may have equivalent or superior efficacy compared with traditional longer (10-14 days) therapies and offers a number of advantages. Results of a number of clinical trials investigating 5-day therapy with oral cephalosporins, new quinolones or ketolides in acute (presumed) bacterial sinusitis in comparison with traditional 10-day treatment courses have been published demonstrating equivalent efficacy of 5-day and 10-day regimens. The evidence reviewed in this article strongly supports reduction of the traditional 10-day course of antibacterial therapy to a 5-day course for uncomplicated acute maxillary sinusitis in adults. Further research related to the duration of antibacterial therapy for sinusitis is needed in children and in adult patients with frontal, ethmoidal and sphenoidal sinusitis.

Acute Disease↗
PubMed1996

Dural-pial arteriovenous malformation with unusual venous drainage.

A 41-year-old female presented with an uncommon mixed dural-pial arteriovenous malformation (AVM) with unusual venous drainage. Angiography at the initial operation for massive intracerebral hematoma in the parietal lobe showed no vascular malformations. Follow-up angiography 3 years later revealed a mixed dural-pial AVM at the previous surgical site. Unexpectedly, the venous drainage from the AVM was not into the patent superior sagittal sinus, but was retrograde into the contralateral cortical veins in the occipital lobe. No skull fracture or sinus thrombosis was demonstrated. The AVM was resected successfully without neurological deterioration. The pial portion of the lesion may have been a congenital anomaly, and the dural portion acquired. The development of a dural AVM at an earlier surgical site is uncommon, and may indicate the possible pathogenesis of acquired dural AVMs unrelated to sinus occlusion or accidental trauma. Furthermore, there are various possible patterns of venous drainage in vascular malformations.

Adult↗
PubMed1988

Management of nontraumatic vascular shunts involving the cavernous sinus.

The authors managed 38 consecutive cases of nontraumatic vascular shunts involving the cavernous sinus. Selective angiography demonstrated 12 carotid cavernous fistulas (CCFs) and 26 dural arteriovenous shunts (DAVSs). Visual disability occurred from glaucoma, venous retinopathy, optic neuropathy, or diplopia. Ten patients with slow-flow shunts and minimal dysfunction were treated medically to lower intraocular pressure (IOP) and/or instructed in manual compression of the internal carotid artery, ipsilateral to the lesion, using the contralateral hand. Percutaneous intraarterial embolization using detachable balloons, isobutylcyanoacrylate, or polyvinyl alcohol particles was successful in 16/18 DAVSs and 9/10 CCFs. The neuro-ophthalmic signs resolved in these 25 cases. Complications occurred in five patients. These included a transient hemiparesis, twelfth nerve palsy, unilateral nasal field loss, a pseudoaneurysm causing a third-nerve paresis, and temporary cavernous sinus thrombosis. Conservative therapy in mild cases and embolization in cases with visual disability or progressive signs are warranted.

Arteriovenous Fistula↗
PubMed2006

Cerebral venous thrombosis and multidetector CT angiography: tips and tricks.

Because of the great diversity of clinical features, its unforeseeable evolution, and a small proportion of cases that will worsen in the acute phase, cerebral venous thrombosis must be diagnosed as early as possible so that specific treatment can be started, typically transcatheter thrombolysis or systemic anticoagulation. Unenhanced computed tomography (CT) is usually the first imaging study performed on an emergency basis. Unenhanced CT allows detection of ischemic changes related to venous insufficiency and sometimes demonstrates a hyperattenuating thrombosed dural sinus or vein. Helical multidetector CT venography with bolus power injection of contrast material and combined use of two-dimensional and three-dimensional reformations (maximum intensity projection, integral display, and volume rendering) provides exquisite anatomic detail of the deep and superficial intracranial venous system and can demonstrate filling defects. However, common variants of the sinovenous system should not be mistaken for sinus thrombosis. A comprehensive diagnostic approach facilitates imaging of cerebral venous thrombosis with multidetector CT.

Cerebral Angiography↗
PubMed1991

Role of anaerobic bacteria in sinusitis and its complications.

Anaerobic bacteria comprise a major portion of the pathogenic bacteria in chronic sinus and ear infections, as well as the complications of these infections. Thus, therapy for frontal osteomyelitis, subdural abscess, orbital abscess, lateral sinus thrombosis, and brain abscess should include antibiotics that penetrate the central nervous system as well as cover anaerobic organisms. Penicillin, metronidazole, and chloramphenicol are three such agents.

Bacteria, Anaerobic↗
PubMed1998

Diagnosis and treatment of dural arteriovenous fistulas.

Dural arteriovenous fistulas (DAVFs) are abnormal vascular connections located within the dura mater which are thought to be promoted by venous hypertension and venous sinus thrombosis. The symptoms associated with DAVFs depend on the direction and adequacy of venous drainage pathways, the amount of arteriovenous shunting and specific location of the fistula. Our experience over a period of eight years with 268 patients suffering from cranial DAVFs in the transverse, sigmoid, superior sagittal, ethmoidal, inferior and superior petrosal, cavernous, and marginal sinuses are presented. The clinical presentation, radiographic evaluation, and treatment modalities for DAVFs in each of these locations are summarized.

Angiography↗
PubMed1998

Development of a subdural vein thrombosis following aggressive factor VII replacement for postnatal intracranial haemorrhage in a homozygous factor VII-deficient infant.

Congenital factor VII deficiency is a rare (1:500,000) autosomally recessive coagulopathy with variable expression and high penetration. In infants the most devastating presentation is that of intracranial haemorrhage. An infant is described with severe factor VII deficiency who developed postnatal intracranial haemorrhage. The baby was treated with factor VII concentrate (ImmunoA.G., Vienna, Austria). Three weeks after the haemorrhage he developed a dural venous sinus thrombosis. Although factor VII-deficient patients may need treatment with factor VII concentrate, this needs to be carefully monitored because of the thrombotic risk.

Cerebral Hemorrhage↗
PubMed2001

The retrograde ventriculosinus shunt: concept and technique for treatment of hydrocephalus by shunting the cerebrospinal fluid to the superior sagittal sinus against the direction of blood flow. Preliminary report.

A retrograde ventriculosinus (RVS) shunt is a watertight connection that delivers excess cerebrospinal fluid (CSF) to the superior sagittal sinus (SSS) against the direction of blood flow. This method of CSF shunting utilizes the impact pressure (IP) of the bloodstream in the SSS to maintain the intraventricular pressure (IVP) more than the sinus pressure (SP) regardless of changes in posture or intrathoracic pressure (ITP) and discourages stagnation and clotting of blood at the venous end of the connection. It also utilizes collapse of the internal jugular vein (IJV) in the erect posture to prevent siphonage. During the past 8 years, 50 RVS shunts were successfully implanted using valveless shunting catheters. There were no problems related to incorrect CSF drainage or sinus thrombosis. The results indicated arrest of the hydrocephalic process, normalization of the IVP and proper shunt function.

Adolescent↗
PubMed1975

Complications of acute frontal sinusitis.

The bone separating the frontal sinus from the anterior cranial fossa and the orbit is often quite thin. This, plus the interrelated venous drainage system of these areas, forms the anatomic basis for serious orbital and intracranial complications that must be recognized early. These include orbital cellulitis and abscess, cavernous sinus thrombosis, subdural and brain abscess and meningitis. Early hospitalization for intravenous antibiotic therapy and, occasionally, emergency surgical drainage are required.

Abscess↗
PubMed1998

Diagnosis of cerebral venous thrombosis with routine magnetic resonance: an update.

Magnetic resonance imaging and angiography is the technique of choice in the diagnosis and follow-up of cerebral venous thrombosis: Thrombosis appears as an absence of flow void on spin echo images and lack of signal in angiographic techniques. The thrombus signal intensity is different on T1 and T2 spin echo weighted images and evolves according to hemoglobin degradation. Recognition of pitfalls and artefacts related to the different magnetic resonance imaging techniques employed is essential to interpret dural venous sinus thrombosis. In this paper the imaging of 27 patients with cerebral venous thromboses is reviewed. We describe the type of signal abnormalities, the different types of clot- and flow-related artefacts, and the indirect signs of cerebral venous thrombosis.

Adult↗
PubMed1999

Stereotactic radiosurgery and particulate embolization for cavernous sinus dural arteriovenous fistulae.

OBJECTIVE: To evaluate the safety and efficacy of stereotactic radiosurgery, either with or without transarterial embolization, in the treatment of patients with dural arteriovenous fistulae (DAVFs) of the cavernous sinus. METHODS: We reviewed the findings, from a prospectively established database, for 20 patients with cavernous sinus DAVFs who were treated with either radiosurgery alone (n = 7) or radiosurgery and transarterial embolization (n = 13) in a 7-year period. The median follow-up period after radiosurgery was 36 months (range, 4-59 mo). RESULTS: Nineteen of 20 patients (95%) experienced improvement of their clinical symptoms. Fourteen of 15 patients (93%) experienced either total (n = 13) or nearly total (n = 1) obliteration of their DAVFs, as documented by angiography performed a median of 12 months after radiosurgery. No patient experienced a recurrence of symptoms after angiography showed DAVF obliteration. Two patients developed new neurological deficits after embolization procedures. One patient exhibited temporary aphasia secondary to a venous infarction; another patient exhibited permanent VIth cranial nerve weakness related to acute cavernous sinus thrombosis. Two patients experienced recurrent symptoms and underwent repeat transarterial embolization at 7 and 12 months; both patients achieved clinical and angiographic cures (5 and 10 mo later, respectively). One patient experienced recurrent visual symptoms and underwent transvenous embolization 4 months after radiosurgery. CONCLUSION: Staged radiosurgery and transarterial embolization provided both rapid symptom relief and long-term cures for patients with cavernous sinus DAVFs. Radiosurgery alone was effective for patients with DAVFs whose arterial supply was not accessible via a transarterial approach, although the time course of symptom improvement was longer, compared with patients who also underwent embolization.

Adult↗
PubMed1987

The acute orbit. Preseptal (periorbital) cellulitis, subperiosteal abscess and orbital cellulitis due to sinusitis.

The clinical picture of an acute orbit, as manifest by preseptal cellulitis, subperiosteal abscess or orbital cellulitis, is still frequently seen in ENT practice. The commonest cause is sinusitis and the authors advocate early surgical intervention in acute orbits due to sinusitis. Clinically, it can be difficult to distinguish between a subperiosteal abscess and orbital cellulitis and a CAT scan may be helpful. Surgically, a subperiosteal abscess is the more important (and probably more frequent) entity as it may require drainage. It may be suspected in an acute orbit which progresses rapidly or fails to settle on treatment and it may require drainage to allow the condition to resolve and avoid potentially damaging sequelae. A classification of the stages of the inflammatory processes seen in the acute orbit is given and the management of 34 cases due to sinusitis is discussed. The other causes of acute orbits are discussed and the further complications that may occur are also mentioned. Blindness, cavernous sinus thrombosis and cerebral involvement are still frequently recorded and death may still occur.

Abscess↗
PubMed1986

[Cerebral venous thrombosis associated with the use of oral contraceptives].

The entity of cerebrovascular diseases associated with the use of oral contraceptives is well known but quite rare in Japan in contrast to Western countries. We recently encountered a 38 years old female with cerebral venous thrombosis considered to be caused by oral contraception. This patient took oral contraceptives for 17 days following therapeutic abortion, and was transferred to our hospital because of disturbed consciousness. CT scans disclosed a right temporo-occipital subcortical hemorrhagic infarction and bilateral thalamic infarction. Cerebral angiograms showed non-filling of cortical veins in the same area. The internal cerebral vein, vein of Galen and right transverse sinus were not visualized either. The hematoma and necrotic tissue were removed to avoid farther neurological deterioration. The brain was swollen and hyperemic, and thrombosed cortical veins were clearly recognized at operation. Twelve cases, including ours, of cerebrovascular diseases associated with oral contraception were reported up to now in Japan, and only 3 of them were diagnosed objectively as venous or sinus thrombosis. The average age of these 12 cases was 34 years old and many of them experienced abortion or therapeutic abortion. There was no relationship between the dose of estrogen and the onset of cerebrovascular diseases. We believe that the onset of this pathological state is based on gynecological hypercoagulable state, and the oral contraception may play a role of a trigger. Oral contraception should be contraindicated in patients with gynecological hypercoagulable state, hypertension and/or smoking habit.

Adult↗
PubMed1977

The tentorium in axial section. I. Normal CT appearance and non-neoplastic pathology.

Bands of increased density representing the free edges and lateral margins of the tentorium were routinely identified on 100 sequential, normal, contrast-enhanced axial CT scans of good quality. Because the tentorium has a complex shape, the exact configuration of these bands varies with the level and the angle of the CT section. Comparison of CT scans with anatomic specimens permits an understanding of these varying configurations, and provides a means to estimate the position of the tentorium on non-contrast CT studies. The CT manifestations of diverse non-neoplastic diseases including subarachnoid hemorrhage, arteriovenous malformation, venous sinus thrombosis and Dandy-Walker malformation may be understood, in part, in terms of the configuration and density of these tentorial bands.

Cerebellar Diseases↗
PubMed2003

Dural arteriovenous malformations of the skull base.

Dural arteriovenous malformations (AVMs) are interesting lesions, which can present as diagnostic and therapeutic challenges. Such AVMs were initially described as located solely in the dural venous sinuses, but during the last decade researchers have discovered them in other locations such as the tentorium and foramen magnum. It is understandable that they can develop in other locations because numerous arteriovenous shunts normally occur all over the dura. Early reports emphasize that they are congenital; however, some investigators have proposed that they are acquired lesions arising after sinus thrombosis and trauma. They also have variable clinical features. From 1975 to 2000 we treated 400 AVMs, of which 46 were dural. Of these 46 dural AVMs, 18 could be classified as skull base AVMs. We restricted the designation of skull base AVMs to those AVMs located in the tentorium or adjacent to bones of the skull base. Two of these AVMs actually had their vascular nidus located in the bone. The common dural sinus AVMs were excluded from this category. The presenting clinical features of these skull base AVMs ranged from headache and pulsatile tinnitus to intracranial hemorrhage. They were treated by a combination of endovascular and microsurgical treatment. The majority of patients had a good clinical outcome. Skull base dural AVMs are an interesting clinical entity. Their clinical course, treatment and final outcome are variable depending on their location. They should be managed by a multidisciplinary approach.

Adult↗
PubMed2002

[A study on the diagnosis and etiology of cerebral venous thrombosis].

OBJECTIVE: To determine the clinical characteristic and common etiologies of cerebral venous thrombosis (CVT) in China. METHODS: Clinical and neuroimaging data of 91 cases of CVT were analyzed retrospectively. RESULTS: 91 CVT patients (49 men, 42 women), aged from 9 to 57 years, were diagnosed with MRI (78 cases, 85.71%), MRA (37 cases, 40.66%) or DSA (32 cases, 35.16%). 27 cases (29.67%) had a clinical pattern of isolated intracranial hypertension, 56 cases (61.54%) of focal deficits and/or seizures, 3 cases of subacute encephalopathy and 5 cases of cavernous sinus thrombosis. Oral contraceptive was the most common cause, being found in 12 cases (13.19%). CONCLUSIONS: Understanding of the clinical characteristics of CVT and using of MRI and MRA examination as early as possible is the key in CVT diagnosis. Oral contraceptive is the most common etiology.

Adolescent↗