Septic cavernous sinus thrombosis complicated by occlusion of the internal carotid artery and multiple embolic strokes after surgery of an anorectal abscess: a clinical chameleon

The Spectrum of Pediatric Infection-Associated Intracranial Arteriopathies and Acute Ischemic Stroke at 2 Eastern Indian Tertiary Care Centres

INTRODUCTION

Major and minor pediatric infections may cause intracranial arteriopathies, the long-term outcome of which we investigated and identified the factors influencing the progression/resolution of arteriopathies.

METHODS

We collected the clinical and radiological data of children aged 1 month-15 years who had ischemic stroke with definite arteriopathy following a recent febrile infection. Repeated neuroimaging was done over the next year to ascertain recurrent strokes and the progression and resolution of arteriopathies.

RESULTS

The anterior circulation was more frequently affected (83.33%), predominantly involving the middle cerebral artery (41.67%), resolving in 20.84% of cases and progressing in 33.33% of cases. Lesions were commonly unilateral (54.17%) and stenotic (75%), resulting predominantly in cortical infarcts (45.83%), with hemiparesis being the most common neurodeficiency. Apart from tubercular meningitis patients, others had a good functional outcome.

CONCLUSION

Lower age, minor infections, and unilateral arteriopathies had a significantly higher chance of resolution. Postviral arteriopathies had a significantly lower chance of progression compared with those following bacterial infections. Progressive and bilateral arteriopathies were significantly associated with worse outcomes and recurrent strokes.

Different causes and diverse outcomes of extremely rare septic cavernous sinus thrombosis complicated with internal carotid artery stenosis

Background

Cases of acute sphenoid sinusitis complicated by septic cavernous sinus (CS) thrombosis and internal carotid artery (ICA) stenosis are rarely reported. Different causative pathogens have been reported for this condition. We present two extremely rare and special cases with diverse clinical presentations and outcomes. Case 1 involved a female patient with less extensive sinusitis, but critical ICA occlusion. Case 2 involved a male patient with extensive pansinusitis, meningitis, cerebritis, and vasculitis due to fungal infection, but less stenosis of the ICA lumen. Both patients underwent surgical debridement and received broad-spectrum antibiotics. Additional anti-fungal medication was also administered in Case 2. However, outcomes differed considerably between cases.

Discussion

Case 1 recovered with minimal neurological deficits and had Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores of 5 and 2, respectively; however, the Case 2 had GOS and mRS scores of 3 and 4, respectively. Although rare, septic CS thrombosis with ICA stenosis can lead to unexpected and severe neurological sequelae. Fungal infection can result in catastrophic complications and poorer prognosis.

Conclusion

In addition to early detection, aggressive surgical debridement and adequate antimicrobial treatment are crucial to satisfactory outcomes in patients with septic CS thrombosis complicated with ICA stenosis.

The clinical characteristics, implicated pathogens and therapeutic outcomes of culture-proven septic cavernous sinus thrombosis

In this magnetic resonance imaging-based study, we investigated the clinical features, neuroimaging features and therapeutic outcomes of 14 adults (eight men and six women; mean age 60.4 years; range 37-77 years) with septic cavernous sinus thrombosis (CST). Of the underlying conditions, 10 had diabetes mellitus and 13 had concomitant sphenoid sinusitis. Headache (n = 13) and ophthalmoplegia (n = 13) were the most common clinical presentations, followed by fever (n = 9) and other neuro-vascular signs and symptoms. The duration from the onset of symptoms to diagnosis ranged from 1 to 61 days, and more than 64% (9/14) of the septic CST patients were diagnosed >7 days after symptom onset. Expansion of the cavernous sinus was the most common neuroimaging feature, followed by convexity of the lateral wall of the cavernous sinus (5) and filling defect of the cavernous sinus (4). Staphylococcal species (spp.) was the most commonly implicated pathogen, followed by Aspergillus spp. Despite treatment, 7% (1/14) of the patients died in the hospital and 67% (8/12) of the survivors had neurological deficits. The duration of onset-to-diagnosis and the presence of hemiparesis were significant prognostic factors. These results provide a preliminary view of this uncommon infectious syndrome. Further large-scale studies are needed to better delineate septic CST in adults.

Septic Cavernous Sinus Thrombosis: Case Report and Review of the Literature

Septic cavernous sinus thrombosis is a rare but serious complication of infection of the cavernous sinuses. There are no randomised, controlled trials of management of this condition and existing reviews of the literature are somewhat dated. The authors report a case with a favourable outcome and then present the findings of a literature review of the management of this condition. Outcome data suggest that corticosteroids are of equivocal benefit whereas antibiotics and anticoagulation are beneficial.