Profile and Outcome of Prospective Non-Septic Lateral Sinus Thrombosis Patients from a Stroke Unit of a Developing Country

Background

Due to effective treatment of middle ear infections there is a change in etiologies causing lateral sinus thrombosis (LST) and outcome. There is a paucity of literature describing homogenous group of patients with nonseptic LST (NS-LST).

Objective

To describe the clinical profile, risk factors, outcome of patients of NS-LST seen at a single center from South India.

Methods and Materials

Prospective, observational study of 100 patients of NS-LST patients, diagnosed by magnetic resonance imaging (MRI) seen at the stroke unit.

Results

During 2 years, 100 patients of NS-LST (isolated: combined: 27:73) (male: female: 44:56), mean age: 31.45 ± 11.13 years, were seen. Subacute presentation (74%) with headache, seizures, focal deficits, and features of raised intracranial pressure were presenting features. Hyperhomocysteinemia (61%), anemia (57%), postpartum state (41%), OCP use (37%), and low VitB12 (32%) were commonly seen risk factors. Imaging with MRI compared withcomputerized tomography (CT) had better diagnostic sensitivity (100% vs. 67%), detection of parenchymal (81% vs. 67%)/hemorrhagic (79% vs. 74%) lesions, and cortical vein thrombosis (31% vs. 15.46%). Treatment with anticoagulation and supportive therapy resulted in good outcome (mRS (0-2)) at 3 months in 81%.There were four deaths, all during admission (one - isolated, three - combined) and 11 patients underwent decompressive surgery. Patients with low GCS level of sensoriumat admission, hemiparesis, combined LST, cerebellar involvement, and decompressive craniectomy had a poor outcome.

Conclusion

This single-center large cohort study of NS-LST patients brings out the clinical features, risk factors (peculiar to developing countries), and the superiority of MRI in the diagnosis. Majority of patients have good outcome, with low mortality with 10% requiring decompressive surgery.

Life-threatening Medical Complications Due to Ovarian Hyperstimulation Syndrome: A Hidden Etiology

Ovarian hyperstimulation syndrome is usually an iatrogenic complication in women taking ovulation induction medications during assisted reproduction. We hereby report the case of a 25 years old female who presented with hypertension, polyserositis with tense ascites and large cystic ovaries. She developed sigmoid and transverse sinus thrombosis. She had undergone a clandestine ovulation induction therapy as a commercial ovum donor. She fitted in severe category of ovarian hyperstimulation syndrome.

Diagnosis and management of a young woman with acute isolated lateral sinus thrombosis

Isolated lateral sinus thrombosis (LST) was mentioned in the past as a complication of middle ear infection. In the recent years, it was not frequently studied. Our patient, a 23-year-old woman who was taking an oral contraceptive pill, displayed 24 hours of migraine, such as headache; her systemic examinations were normal. She underwent neuroimaging examinations in the first 36 hours of admission. Native head computed tomography (CT) revealed hyperdensities along the left tentorium, involving the left lateral sinus (LS). Cranial magnetic resonance imaging (MRI) showed hypointense signal on MRI T2*SW (susceptibility-weighted) in the region of the left LS. MR venography noted the absence of flow-related signal within the left LS. The clinical symptoms, signs and neuroimaging results formulated the diagnosis of left isolated LS thrombosis. Laboratory data demonstrated an elevated D-dimer and homozygosity for the factor V Leiden mutation. She was immediately started on anticoagulation in the form of low-molecular-weight Heparin; then, she was treated with Warfarin for an indefinite duration. The headaches resolved within two days and her neurological examination was also normal. A second MR venography achieved after two weeks demonstrated complete recanalization of the venous sinuses. We did not observe any LST recurrence, deep vein thrombosis or pulmonary embolism during one year of follow-up. The early initialization of anticoagulation produced a favorable evolution. An acute isolated left LST could be identified in her case on the head CT combined with MRI and MR venography.

Intracranial venous sinus thrombosis as a complication of otitis media in children: Critical review of diagnosis and management

OBJECTIVES

Otogenic lateral sinus thrombosis (LST) is a rare intracranial complication of acute otitis media (AOM), which can lead to severe neurological sequelae and death. The aim of this study was to analyze the clinical presentation, management and outcome of LST in children, investigating a possible correlation between clinical aspects, radiological findings and anatomical variations.

METHODS

At a tertiary Italian hospital, a retrospective review was conducted on the medical records of eight patients diagnosed with otogenic LST over a 3-year period. Four children were males and mean age was 4.7 years.

RESULTS

All patients had a history of otitis media at diagnosis and 4/8 presented also with more than one neurological sign or symptom. Mastoiditis signs were detected in 5/8 patients. Thrombosis was diagnosed by computed tomography, enhanced magnetic resonance and magnetic resonance venography. Treatment was medical, alone or combined with surgery. Medical treatment consisted in anticoagulants eventually combined with anti-edema medication on clinical basis. Mastoidectomy and/or myringotomy±trans-tympanic drainage placement were performed in 7/8 patients. Complete vessel recanalization was obtained in 6/8 children after a median follow-up time of 4.8 months. No complications, neither clinical sequelae occurred. In our series, neurological signs and symptoms were significantly associated with the presence of hypoplasia of the contralateral venous sinus (p=0.029).

CONCLUSION

LST is a severe condition occurring even in absence of otological signs, and despite adequate antibiotic therapy for AOM, which should be ruled out and promptly treated. A dominant neurological presentation is associated in our series with anatomical variations of cerebral sinus venous drainage patterns. This should be carefully evaluated and considered in diagnosis, treatment planning and prognosis.

Otogenic lateral sinus thrombosis: case series and controversies

OBJECTIVES

The aim of this study is to (1) report the clinical presentation, treatment, and sequelae in a series of pediatric patients with otogenic lateral sinus thrombosis and (2) to review the most controversial aspects of management of this rare intracranial complication of otitis media.

METHODS

Retrospective chart review of inpatients treated for central venous thrombosis at a tertiary care facility between 1996 and 2012.

RESULTS

Five pediatric patients (four male, one female) were identified with otogenic lateral sinus thrombosis. Age at presentation ranged from 13 months to 15 years. All underwent a surgical procedure, ranging from a simple myringotomy with tympanostomy tube placement to tympanomastoidectomy and internal jugular vein ligation or craniotomy. Three were anticoagulated with unfractionated heparin with subsequent transition to low molecular weight heparin of variable duration. One patient developed a non-life-threatening intracranial hemorrhage while on long-term anticoagulation. Follow-up imaging, when available, did not directly correlate complete thrombus resolution with use of anticoagulation or with persistent symptoms.

CONCLUSIONS

Otogenic lateral sinus thrombosis is a rare intracranial complication of otitis media with significantly reduced morbidity and mortality in the modern era of antibiotic treatment, surgical intervention, and anticoagulation therapy. Due to the rarity of this condition today, the recommended extent of surgical intervention and need for routine anticoagulation are unclear, and requires further data to determine definitively.

Contemporary management of pediatric lateral sinus thrombosis: a twenty year review

OBJECTIVES

A case of pediatric otogenic lateral sinus thrombosis is reported, followed by a substantive literature review.

DESIGN

104 patients were reviewed, culled from published case reports from 1993 to 2011 on the PubMed database.

METHODS

All full text case reports on the PubMed database from 1993 to 2011 with patients less than or equal to 16 years of age that outlined specific treatments were included.

RESULTS

73% of patients were male and average age of presentation was 7.7 years. The most common symptoms were fever, headache, and otalgia, while the most common signs included otorrhea and neck stiffness. CT scans had a sensitivity of 87% and MR studies had a sensitivity of 100%. Single bacterial organisms were isolated in 46% of cases, with beta hemolytic streptococcus, streptococcus pneumoniae, and staphylococcus aureus being most common. Management included broad spectrum antibiotics (100%), mastoidectomy (94%), manipulation of the thrombosed sinus (50%), and anticoagulation (57%). The mortality rate was one in 104 patients. Morbidities occurred in 10% of patients and included cranial nerve palsy, sensorineural hearing loss, stroke, and septic hip joint.

CONCLUSION

Lateral sinus thrombosis is a rare but treatable complication of otologic disease in the pediatric population, warranting a high index of suspicion. Management should include broad spectrum antibiotics and surgical removal of all perisinus infection. Anticoagulation is not definitively associated with improved outcomes and warrants further investigation.

Simultaneous appearance of cerebral venous thrombosis and subdural hematomas as rare cause of headache in puerperium following epidural analgesia: a case report

The aim of this study is to report the first case of simultaneous appearance of cerebral venous thrombosis (CVT) and bilateral subdural hematomas (SDHs) following epidural analgesia for labor and delivery and to point out the difficulty of establishing such a diagnosis in the presence of postpartum headache. A 26-year old primigravida with a history of epilepsy received epidural analgesia for delivery. Three days after the uneventful spontaneous vaginal delivery she complained about the headache. Patient responded very well to the pain medication and oral hydration, and the headache was relieved. Ten days after the delivery, the headache reoccurred, and an epidural blood patch was performed that successfully relieved her symptom. Stronger progressive headache with nausea reappeared two days later and the parturient was readmitted to hospital. Urgent neuroimaging examinations detected CVT of right the transverse sinus, ipsilateral cortical veins, and partially occluded superior sagittal sinus, as well as bilateral subacute/chronic SDHs. The treatment of the patient with low molecular weight heparin and antiaggregation therapy was effective. In this case, the diagnosis was delayed because of atypical clinical presentation and potentially confounding events (epidural analgesia and assumption that it was a case of PDPH). It is important to carefully observe patients in such conditions and promptly conduct suitable diagnostic tests. Otherwise, unrecognized intracranial complications and delay of appropriate therapy could be life-threatening.

[Some clinical and imaging aspects of lateral sinus thrombophlebitis]

AIM

This article focuses on the lateral sinus thrombophlebitis, which is a serious complication of the supurated otopathies.

MATERIAL AND METHODS

It is based on a study of a significant number of both exo- and endocranial complications treated in the the "Sf Spiridon" Hospital- ORL department and at the "Prof. dr. N. Oblu"- Neurosurgery department (57 out of 251 cases admitted in the past 5 years).

RESULTS

Among the 57 cases, there were 8 lateral sinus thrombophlebitis, as well as 6 cases where meningitis coexisted with other endocranial complications, such as lateral sinus thrombophlebitis or brain abscess. The article contains details about some cases with special problems of diagnostic and treatment.

CONCLUSIONS

The symptoms of the presented cases are completely different from the common symptomatology. However, the diagnostic of such cases is possible due to the modern imaging methods as well. The lateral sinus thrombophlebitis is usually determined by different causes, one of them being the misuse of the antibiotics (class and daily/total dose). When endocranial complications occur the symptoms of the meningitis are masking the symptoms of other complications. Even if the CT scan or MRI exams performed right on the patient's admission show no other complications, the patient should be followed for a period of 15 up to 30 days after the treatment of the meningitis, by repeating imaging tests to identify a possible complication.

Nonseptic lateral sinus thrombosis: the role of the otolaryngologist

Nonseptic lateral sinus thrombosis differs from septic lateral sinus thrombosis in that it is not associated with ear or sinus infection. Mastoid changes are frequently detected on computed tomography or magnetic resonance imaging in cases of nonseptic lateral sinus thrombosis. An otolaryngologic evaluation is usually required to exclude coexisting mastoiditis.

[Impairment of optic nerves as the result of cerebral sinus venous thrombosis]

Cerebral venous sinus thrombosis is a disease with potentially serious consequences and usually affecting young to middle aged people. Headache was the most frequent symptom. Diagnosis is based on clinical signs, radiological imaging (CT scan, MRI), bacteriological examinations and laboratory biochemical tests. Mastoidectomy and tympanic cavity drainage is performed in cases with lateral sinus thrombosis in acute mastoiditis. Intravenous antibiotics therapy should be continued for 2 weeks. Anticoagulants should be given, taking into consideration parameters of coagulation system and the type of thrombus. Because of moderate to high mortality rate, patients should be closely monitored.

PURPOSE

Presentation of the case of bilateral optic nerve atrophy after extensive thrombus of sigmoid and right transverse sinuses.

MATERIAL AND METHODS

We present the case of a boy, who suffered inflammation of venous sinuses of cranial basis, when he was 6 years old. It happened 1 month after right mastoid bone injury. In the course of this disease, intracranial hypertension with bilateral optic disc swelling appeared.

RESULTS

5 years after thrombosinusitis, the child has pale optic discs, changes in the peripheral visual field, abnormal VEP and incorrect contrast sensitivity.

CONCLUSIONS

Trauma in the region of the temporal bone may cause hard complications from thrombosinusitis, and lead to bilateral optic damage.

Managements for lateral sinus thrombosis: does it need the ligation of internal jugular vein or anticoagulants?

The purposes of this study were to review the clinical characteristics and treatment outcomes of patients with lateral sinus thrombosis (LST) and to discuss the need of internal jugular vein (IJV) ligation or anticoagulants. We retrospectively reviewed the charts of five patients (1 male and 4 female) with LST. The chief complaints were otalgia, fever, mastoid tenderness, and neck pain. All patients were confirmatively diagnosed with MRI-Venography or Angio-CT scans. The patients were treated with appropriate antibiotics and operations including mastoidectomies with/without thrombectomy according to their suspected disease course. The authors did not perform IJV ligation and use anticoagulants in all cases, but there were no mortalities or morbidities. IJV ligation and use of anticoagulants do not seem to be essential procedures for the management of LST, and it should be considered carefully according to the extents of disease and the state of patients.

[Case of transient cortical blindness due to thrombosis of the transverse sinus]

An 62-year-old man presented visual impairment and generalized seizure. Brain CT performed on the day of admission showed thrombus in the right transverse sinus, and DWI showed high intensity areas in the bilateral occipital and parietal lobes. According to bilateral occipital lobe lesions, we considered his visual impairment as cortical blindness. He was diagnosed as venous sinus thrombosis and intravenous heparin, edaravone and osmotic diuretics were administered. MR venography performed after starting of intravenous treatment showed flow gap in the left transverse sinus but no abnormalities in the right transverse sinus. On the second day of hospitalization, his cortical blindness showed improvement and thrombus in the right transverse sinus were disappeared. This indicated that his left transverse sinus originally hypoplastic, thrombus and hemostatis in the right transverse sinus (his dominant side) caused his cortical blindness and generalized seizure. There was a recanalization in the right transverse sinus after heparin therapy.

Lateral sinus thrombosis as a complication of acute mastoiditis

Lateral sinus thrombosis is a rare complication of middle ear diseases: in children, it is usually related to acute otitis media, but it is also found in adults with chronic otitis. It was more frequent in the pre-antibiotic era and mortality was high. The Authors present a paediatric case of lateral sinus thrombosis in which they describe the clinical approach and related literature.

Lateral sinus thrombosis

We describe four cases of lateral sinus thrombosis secondary to otitis media. They presented with low-grade fever, headache, nausea, vomiting and ear discharge. One patient had facial nerve palsy. CT scan was helpful in managing these patients. They were treated with antibiotics followed by surgery. Two patients had intracranial abscesses and were treated accordingly.

[Dural sinus thrombosis]

Dural sinus thrombosis is a rare condition and is often underdiagnosed. Because of its potentially lethal complications, it should always be considered in acute headache differential diagnosis. The authors present a report of two cases, both diagnosed on our department. They make an approach to clinical presentation, diagnosis and treatment of this disease.

Management of Lateral Sinus Thrombosis in Chronic Otitis Media

OBJECTIVE

To present our experience with the diagnosis and treatment of lateral sinus thrombosis (LST) secondary to otogenic disease.

PATIENTS AND METHODS

We have retrospectively reviewed all the cases of LST caused by chronic otitis media in ten years.

RESULTS

In our series of five patients, four patients were successfully treated by surgery without opening the sigmoid sinus. On the other hand, one of our patients developed hydrocephalus and ataxia during preoperative antibiotic treatment.

CONCLUSION

Most patients with thrombotic/nonabscessed sinuses will have successful outcomes with this approach, but careful observation is needed, given the possibility of advancing disease.

Otitic hydrocephalus associated with lateral sinus thrombosis and acute mastoiditis in children

The incidence of intracranial complications of acute otitis media (AOM) has decreased and the need for operative and medical treatment is declined during the antibiotic era. To describe pathognomonic signs, evaluation management, operative findings, clinical course and outcome of otitic hydrocephalus and lateral sinus thrombosis as complications of AOM and mastoiditis in pediatric patients. Two children, 9 and 13 years old, with the diagnosis of OH and TK and MRI findings are presented. Intracranial complications in children resulted from unsuccessful treatment of AOM, which led to acute mastoiditis and lateral sinus thrombosis. Both of the presented children had thrombus in their sigmoid sinus preoperatively, demonstrated by MRI, causing decreased blood flow. Both patients underwent a mastoidectomy and delamination of sigmoid sinus with puncture of sinuses. After medical and surgical treatment, blood flow through the sinus increased significantly. In both cases signs of increased intracranial pressure ceased. The clinical presentation of otogenic lateral sinus thrombosis (LST) as a complication of acute otitis media (AOM) can be masked by antibiotic treatment. The episodes of vomiting, headache, visual impairment and a history of AOM seem to be indicative for otitic hydrocephalus. MRI scans of patients with similar symptoms should be carefully studied to facilitate the early diagnosis of dural sinus thrombosis with increased intracranial pressure. Contrast-enhanced computed tomography scan and magnetic resonance imaging play a major role in determining diagnosis and treatment plans in this intracranial complications. Management included systemic antibiotics, short-term heparin anticoagulation and surgical decompression. In our patients intensive i.v. antibiotic treatment, steroids, anticoagulants and surgery led to a significant improvement in the clinical condition.

What happens to the lateral sinus following thrombosis? A case of failed recanalization

Recanalization of the lateral sinus thrombosis is an expected outcome in patients who respond to treatment. We report a case of persistent lateral sinus thrombosis many years after treatment for peri-sinus infection.

Diagnosis and Management of Lateral Sinus Thrombosis

OBJECTIVES

To define the contemporary management of septic otogenic lateral sinus thrombosis.

STUDY DESIGN

Retrospective case series identified through database search of otologic surgical cases managed by a single surgeon in four teaching hospitals over a 6-year period.

METHODS

Twelve patients presenting with lateral sinus thrombosis of otogenic cause were the subjects of this study. Patients with incomplete medical records or unknown outcomes were excluded.

RESULTS

Lateral sinus thrombosis was the result of chronic otitis media in 50% of cases, with five of these patients having cholesteatoma. In addition, there were seven associated intracranial complications in six patients in this series. All patients underwent medical and surgical treatment. Aggressive and early surgical treatment was tailored to the degree of preoperative and intraoperative findings. The sigmoid sinus was resected in six of the patients with a variable degree of inferior margin proportional to the extent of thrombosis. Thrombectomy alone under vascular control with reestablishment of flow was used to remove the septic thrombus in the other six patients. There were no complications in these patients.

CONCLUSION

Early and aggressive surgical intervention of this otogenic complication can potentially minimize mortality, hospital stay, and length of medical treatment.

Otitic hydrocephalus: role of radiology for diagnosis

OBJECTIVE

The pathogenesis of otitic hydrocephalus remains unclear. The use of radiological examination is very important to clarify both the diagnosis and the pathogenesis. In this article the role of magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) is discussed.

PATIENTS

Two patients with the diagnosis of otitic hydrocephalus and their MRI and MRV findings are presented.

RESULTS

Both of the patients presented had thrombus in their transverse sinuses pre-operatively demonstrated by MRI causing decreased flow on MRV. After the treatment blood flow through the sinus increased significantly as the symptoms subsided.

CONCLUSION

MRI and MRV are valuable tools for diagnosis and follow-up of otitic hydrocephalus.

Complications of otitis media: an evolving state

The advent of antibiotics in the 1930s and 1940s has led to a decline in the incidence of otitis media complications. However, otitis media and its complications are continuing to evolve owing to the emergence of antibiotic resistance and the introduction of pneumococcal vaccines. Modern high-resolution computed tomographic scans have allowed for earlier diagnosis when signs and symptoms are present, but a high index of suspicion must be maintained because the clinical presentation may be quite subtle. The intent of this article is to discuss the intracranial and extracranial complications of acute and chronic otitis media. The clinical presentation, work-up, and management of the individual complications are presented.

Contraceptive-Related Cerebral Venous Thrombosis With Profuse Vaginal Bleed

INTRODUCTION

Women on hormonal therapy for menorrhagia are at risk for cerebral venous thrombosis.

CASE REPORT

This scenario may become complicated when there is profuse vaginal bleed with the withdrawal of hormonal therapy. There are no reports describing the possible therapeutic approaches in this clinical situation.

RESULTS

A 42-year-old female with a history of uterine fibroids and menorrhagia taking an estrogen-progesterone combination pill presented with seizure clusters. Neuro-imaging showed lateral sinus thrombosis and biparietal hemorrhagic infarcts. Withdrawal of the contraceptive pill was associated with profuse vaginal bleed, leading to hemodynamic instability and the need for multiple blood transfusions. As an emergent procedure to stop the vaginal bleeding, the patient was implanted with a levonorgestrel intrauterine system; with this, vaginal bleed stopped within 12 hours with hemodynamic stability. Subsequently, the patient was treated with unfractionated heparin followed by warfarin (target international normalized ratio: 2.5-3). She made a good neurological recovery.

CONCLUSION

This case illustrates that LNG-IUS can be an innovative choice for local hormonal therapy in a patient with OCP-related cerebral venous thrombosis and simultaneous vaginal bleeding.

Pediatric Lateral Sinus Thrombosis: Retrospective Case Series and Literature Review

OBJECTIVE

A comparison between the literature and our management of pediatric patients presenting with otogenic lateral sinus thrombosis.

DESIGN

A retrospective case series of five pediatric patients.

SETTING

Four patients were treated at BC Children's Hospital, whereas the fifth patient was treated in New Westminster, BC. All were treated between 1994 and 2001.

METHODS

A retrospective chart review was conducted with a literature review for otogenic lateral sinus thrombosis.

MAIN OUTCOME MEASURES

Treatment success was based on resolution of acute infection and neurologic symptoms.

RESULTS

Five patients, four males and one female, aged 2 to 14 years were reviewed. Three patients were treated successfully without mastoidectomy. One patient received a mastoidectomy that yielded no pus or granulation tissue within the mastoid cavity. One patient required a mastoidectomy after failure to respond to bilateral myringotomy and tympanostomy tube insertion. Although no pus was seen in the mastoid cavity, perisinus pus was found after unroofing the sigmoid sinus plate; free flow of blood was obtained on needle aspiration of the sinus, and the sinus was not surgically opened.

CONCLUSION

The current literature states that the management of otogenic lateral sinus thrombosis includes high-dose intravenous antibiotics with a mastoidectomy and possible opening of the sinus. In our retrospective case series, three of five patients recovered completely without mastoidectomy, and a fourth had a mastoidectomy deemed to have been unnecessary. We conclude that intravenous antibiotics and insertion of a tympanostomy tube are sufficient treatment for selected cases of otogenic lateral sinus thrombosis. Mastoidectomy with possible opening of the sinus should be reserved for patients refractory to the above conservative treatment.

Management of otogenic lateral sinus thrombosis

PURPOSE

Lateral sinus thrombosis (LST) is a rare but potentially devastating complication of otitis media. We review the clinical presentation, evaluation, management, operative findings, and outcomes of this serious complication.

MATERIAL AND METHODS

A retrospective chart review was performed at a teaching hospital of all patients diagnosed with an otogenic lateral sinus thrombosis between 1992 and 2002. Data on patients with otogenic LST were collected and analyzed.

RESULTS

Eleven patients were identified with a diagnosis of lateral sinus thrombosis, and all had a chronic otitis media. The most common presenting symptoms were headache, otalgia, and fever. Radiologic evaluation included computed tomography scan, magnetic resonance imaging, or magnetic resonance venography. All patients had radiographic evidence of LST preoperatively. The thrombosed sinus was on the right side in 6 patients and on the left side in 5 patients. The majority of patients (8 of 11) had a second concomitant intracranial complication. All patients underwent a mastoidectomy. The thrombus was removal in 7 cases, whereas only needle aspiration of the sinus was performed in 4 cases. Gram-negative bacilli and anaerobes were the most common organisms. There were no deaths but sequelae included VI nerve palsy, ataxia, and dead ear.

CONCLUSION

LST as a complication of otogenic infections may still pose a serious threat that warrants immediate attention and care. It is frequently associated with other intracranial complications. Contrast-enhanced computed tomography scan and magnetic resonance imaging plays a major role in determining diagnosis and treatment plans. The availability of broad-spectrum antibiotics has improved our management significantly. Conservative surgical intervention including eradication of all perisinus infection and needle aspiration of the sinus seems to be effective.

Lateral sinus thrombosis associated with zoster sine herpete

Herpes zoster results from reactivation of the varicella zoster virus (VZV). Zoster sine herpete (ZSH) is an uncommon manifestation of VZV infection and presents with similar symptoms but without the vesicular rash. We describe an unusual case of lateral sinus thrombosis (LST) that developed during the clinical course of ZSH in the C2 distribution. A 55-year-old woman presented with a 3-day history of left temporal and postauricular pain, nausea, vomiting, and mild photophobia. She denied otalgia, otorrhea, and hearing loss. Examination revealed hyperesthesia in the left C2 nerve root distribution without evidence of herpetic rash. A computed tomography scan showed minimal fluid in the left mastoid cavity (not mastoiditis) and thrombus within the left lateral and sigmoid dural sinus. Magnetic resonance imaging and magnetic resonance angiogram confirmed these findings. Laboratory studies revealed elevated neurotrophic immunoglobulin G levels to VZV. Hypercoagulable studies were normal. She was subsequently treated with Neurontin, acyclovir, and anticoagulation. Her symptoms improved, and she was discharged 3 days later. LST is generally a complication of middle ear infection. Nonseptic LST, however, may result from dehydration, oral contraceptive use, coagulopathy, or thyroid disease. This unusual case raises the suspicion that thrombosis resulted from VZV associated thrombophlebitis in the ipsilateral cerebral venous sinuses along the second cervical nerve root distribution. A high index of suspicion is necessary in such cases so that a different treatment course can be identified and antiviral medication initiated promptly.

MR venography in idiopathic intracranial hypertension: unappreciated and misunderstood

BACKGROUND

Venous sinus disease must be excluded before diagnosing idiopathic intracranial hypertension but is found only rarely in typical cases. Magnetic resonance venography (MRV) is the technique of choice for investigating this, and provides images that are diagnostic and easy to interpret. However, recent work using more invasive techniques has documented pressure gradients and stenoses in the lateral venous sinuses in many cases of idiopathic intracranial hypertension.

OBJECTIVE

To examine the reason for this discrepancy and to establish whether there are characteristic appearances on MRV in idiopathic intracranial hypertension that are routinely overlooked in clinical practice.

METHODS

MRVs from 20 patients with idiopathic intracranial hypertension were reviewed, unblinded, by two neuroradiologists, and their appearances rated for focal narrowings and signal gaps. A control group of 40 asymptomatic volunteers, matched for age and sex with the patient group, was recruited prospectively for MRV, and their scans rated in the same way.

RESULTS

The lateral sinuses presented a range of appearances with quite different distributions in the two groups (p<0.001). Bilateral lateral sinus flow gaps were seen in 13 of 20 patients with idiopathic intracranial hypertension and in none of 40 controls.

CONCLUSIONS

A historical failure to use normal healthy controls to establish the boundaries between imaging artefact, normal anatomical variant, and disease means that the pathological significance of the different appearances of the lateral sinuses on MRV has not so far been appreciated.

Management of lateral sinus thrombosis: update and literature review

The management of four cases of lateral sinus thrombosis (LST) over a four-year period at the Royal Darwin Hospital is presented in this retrospective review. The patients were aboriginal and presented with otalgia, otorrhoea and sepsis. Two cases had an associated complication of an otitic hydrocephalus and a subperiosteal abscess. Cholesteatoma was found in three cases. Computed tomography (CT) scan confirmed the LST in three cases. Three patients were anaemic and thrombocytopenic. All patients had positive blood cultures. The organisms were predominantly mixed anaerobes and Bacteroides species. Three patients were managed surgically as a two-stage procedure. One patient was managed as a single-stage procedure with a modified radical mastoidectomy. Therapeutic anticoagulation was utilized in one case. There were no deaths. The prognosis of LST is good if treatment is instituted early with broad-spectrum intravenous antibiotics and surgery. The role of clot removal at surgery and the use of anticoagulation are discussed in this paper.

When Can Lateral Sinus Thrombosis Be Treated Conservatively?

OBJECTIVE

The purpose of this study was to review the clinical manifestations, radiologic findings, and treatment modalities of our cases with lateral sinus thrombosis (LST).

METHOD

Documents of patients with LST, diagnosed and treated from 1995 to 2001 in our clinic, were examined retrospectively.

RESULTS

Four patients with the diagnosis of LST were treated during this period. Among the clinical manifestations of these patients, the most frequently encountered symptoms were earache and headache, in addition to otorrhea and hearing loss. Four cases had chronic otitis media, three with cholesteatoma and one with polyps. Delta sign was detected in three cases on computed tomography, whereas a suspicious image was noted in one case. This case underwent magnetic resonance angiography, and the diagnosis of LST was established conclusively. In two cases, because pus was aspirated via lateral sinus punctures performed intraoperatively, these sinuses were explored and obliterated following radical mastoidectomy. Because pus was not aspirated via punctures of the other two cases, their sinuses were not explored. Only radical mastoidectomy was performed surgically for these cases. Dual antibiotics and low-dose anticoagulant therapy were given concomitantly to all cases in the postoperative period. Recanalizations of the nonobliterated lateral sinuses were detected with Doppler ultrasonography of internal jugular vena at 15 days and 3 months after the termination of postoperative treatment.

CONCLUSION

Clinical findings and radiologic techniques play an important role in the diagnosis of LST. In the treatment, if pus is found in the lateral sinuses, it is necessary to explore, clean, and obliterate them, whereas in cases in which the aspirates do not contain pus, mastoidectomy is sufficient. On the other hand, a low dose of anticoagulant can be used together with antibiotics in the nonobliterated lateral sinuses.

A rare and serious complication of chronic otitis media: lateral sinus thrombosis

Before the antibiotic era, lateral sinus thrombosis (LST) was the most frequent complication of otitis media. With the widespread usage of antibiotics, its occurrence is rare. Nevertheless, it is still a major complication of middle ear disease. LST mortality fluctuates between 5 and 35%. The major clinical symptoms of patients with LST are pain in the mastoid region, spiking fever, anemia and general health disorders. Computed tomography, magnetic resonance imaging and angiography are the most helpful in diagnosis, but the final diagnosis is made by surgical exploration. Three cases with LST are presented, and signs, diagnosis and treatment of disease are discussed.

Mastoid air sinus abnormalities associated with lateral venous sinus thrombosis: cause or consequence?

BACKGROUND

Mastoiditis is a known cause of lateral venous sinus thrombosis (LST). We have encountered patients with LST associated with mastoid abnormality on MRI without any clinical signs of infection; the significance of these abnormalities is uncertain. This study examines the relationship of LST and mastoid air sinus abnormalities systematically.

SUMMARY OF REPORT

We performed a retrospective clinical and radiological review of a series of 26 patients with cerebral venous thrombosis. Mastoid abnormalities were detected ipsilateral to 9 of 23 thrombosed lateral sinuses (39%) and 0 of 29 unaffected lateral sinuses (P<0.001). No patient had clinical evidence of mastoiditis. Eight of 9 patients with mastoid abnormalities were treated without antibiotics; all made uneventful clinical recoveries. Repeated MRI in 1 patient revealed reversal of the mastoid changes.

CONCLUSIONS

The mastoid changes observed are likely to be due to venous congestion as a consequence of LST, not mastoiditis.

Sigmoid sinus thrombosis with contralateral abducens palsy: first report of a case

Intracranial complications of acute and chronic otitis media can be difficult to recognize because the signs and symptoms are often subtle. This article describes a case of one such complication--sigmoid sinus thrombosis--that was manifested by a contralateral abducens palsy. The author believes that this is the first reported case of such an occurrence. This article also reviews the differential diagnosis of increased intracranial pressure and discusses the recognition and management of lateral sinus thrombosis.

Combined risk factors contributing to cerebral venous thrombosis in a young woman

Cerebral venous thrombosis is a rare condition affecting predominantly adolescents or young adults. The presentation is often non-specific, and delay in diagnosis is common. The otolaryngologist may be consulted about the radiological findings of lateral sinus thrombosis and mastoid changes. The association of congenital thrombophilia with unusual presentations of venous thrombosis, especially in young individuals is now well documented. We present a case of lateral and sagittal sinus thrombosis complicated by cerebral venous infarction in a girl with protein C deficiency and masked mastoiditis. Unusual forms of venous thrombosis, including cerebral venous thrombosis may develop in association with a single risk factor for thrombosis, but additional risk factors should be sought especially when thrombosis presents in very young individuals. This case draws attention to the multi-causal nature of cerebral venous thrombosis in young adults, and highlights the issue of masked mastoiditis. A coordinated approach by otolaryngological and haematological teams is recommended in such cases.

Otogenic lateral sinus thrombosis--a case report

INTRODUCTION

We portray and discuss a case of lateral sinus thrombosis following acute otitis media and mastoiditis.

CLINICAL PICTURE

The patient presented with otorrhoea, otalgia, neck pain, fever and chills.

TREATMENT

Cortical mastoidectomy was performed. Intravenous antibiotics and heparin were administered.

OUTCOME

The patient had a complete recovery with no sequelae.

CONCLUSIONS

Neurotologic complications of suppurative otitis media like meningitis, cerebral abscess, extradural abscess and dural sinus thrombosis are rare in the antibiotic era. Hence, doctors today have to maintain extra vigilance and a high index of suspicion for such complications.

Osteomyelitis, lateral sinus thrombosis, and temporal lobe infarction caused by infection of a percutaneous cochlear implant

OBJECTIVE

Cochlear implantation has become a routine operation in the last 10 years. The most common soft tissue complications with transcutaneous cochlear implants include infection or necrosis of the flap and extrusion of the implant and device failure. The most common complication reported with percutaneous devices include minor skin irritations at the pedestal site, retraction of skin from the pedestal site, and loosening of screws that retain the pedestal. We describe one case of lateral sinus thrombosis and secondary temporal lobe infarction caused by infection of a screw anchoring the percutaneous pedestal of an Ineraid implant.

STUDY DESIGN

Case report.

SETTING

Tertiary referral center.

CONCLUSIONS

Intracranial complications of a percutaneous bone-anchored pedestal may occur with little prodrome. Computed tomography (CT) scan of the pedestal and bone anchoring screws may be indicated if local evidence of infection persists.