Journal of Neuro-Ophthalmology, March 1986, Volume 6, Issue 1

Unilateral septic cavernous sinus thrombosis. A case report with digital orbital venographic documentation.

In its early stages, septic cavernous sinus thrombosis may be difficult to differentiate from orbital cellulitis. We describe a case in which digital subtraction orbital venography proved to be a superior technique for clarifying this clinical dilemma, and we stress the clinical importance of making this differentiation.

Unilateral Septic Cavernous Sinus Thrombosis A Case Report with Digital Orbital Venographic Documentation Massimo S. Fi,1l1d,1(\1, ;-"I.D., Robert H. Spector, M.D., Thomas M. Hartmann, i\I.D., and Ira F. Braun, M.D. In Its earl\' St,l~l'S, sq,tlc C,ll'l'r!lllllS sinus thwl1lbosis mal' be ditilclIlt tll dliil'fenlI,llt' tWill orbital cellulitis. \\'e' descrIbl' a caSl' III which di~lt,ll sllbtr,Ktillll llrbiLll I·t'n,)~ra~'hl' pr')\'l'd to be ,1 SllperIllr kchniqul' ior c1,UI­h'ing this c1inlc,ll dIll'lllllla, and Ill' strl''>'> thl' c1lllical lmr~rtanct' lli ma"in~ thiS diiil'rentiation From the Department of Surgl'rv, DII'"ion ot Nl'urosurgl'rv (MSFj, Department of Ophthalmologl' (RHS). ,1I1d lkp,Htn1l'l1t of Radiology, Division of Nl'uroradio!ogy (TMH, Ifll), Eillory University School of Medicine, Atlanta, Gl'orgi,l. Address correspondence and reprint requests to Dr. M. S. Fiandaca at Division of Neurosurgery, Fnlllry CliniC L\h~ Clifton Road, N.E., Atlanta, GA 30322, USA 35 Septic cavernous sinus thrombosis, once consid­ert'd a uniformly fatal condition, noll' has a rather hopeful prognosis, owing tll the Widespread use llf effective antibiotic therapy (1,2), The clinical profile of septic cal'ernous sinus thrombosis, first described bv Knapp in IHhH (3). comprises unilat­eral proptosis and lid l'dema, sometimes asso­ciated with severe ocular pain, ophthalmoplegia, prostration, and fevl'f. Unchecked, the orbital pro­cess quicklY spreads from one e\'e to the other and can eventuallv produce Widespread intracranial infection and death, In the earlv stages of septic ca\'ernous sinus thrombosis, prior tll the del'elllpment llf bilateral ocular findings, differentiating it from llrbital cel­lulitis may be difficult (2,..),), The clinical distinction is more than academic, since each condition re­quires a different antibilltic regimen (:"-7) and has different posttreatment sequelae (..),-7), We de­scribe a case in II'hich till' clinical picture and the compUlt'd tllmographic scans llf the llrbits and C,lVernous sinuses were suggl'stil'e of the diag­nosis ot unil,llt'r,ll Sl'ptiC C,l\'t'rnllUS sinus thrl)m­bosis, which II'<lS cllnfirnll'd b\' digit,ll subtractilln orbi tal venogr,l pi1\', CASE REPORT A ..),LJ-ve,H-old m,lIl with insulin-dependent dia­betl's 1lll'llitus dl'\'l'loped fe\'er (lllYF) of rapid onsl'l, m,llaisl', and painful swelling of the right eye, He W,lS describl'd bv ,1 pl1\'sician as lethargic, with chemosis 'lIld proptosis of the right globe. Eye mOVellll'nts, \'ision, pupillary function, and the relll,linder of the neurological examination were said tll bl' normal. Blood studies showed ke­toacidosis, hyperglvcemia, and polymorphonu­clear leukocvtosis, Skull films and a computed to- /\1 " I 1/1 Nil/Ie/I 1./I1L ll111gr,lphil' sr,lll III till' 11L',ld dl'Ill11llstrdtl'd pdllSi­Ilusitis. Spill,lI Iluid, llhldillVd Illlh .111 "11('llill,~ f'rl'ssun' III 2\() 111111 Ilcl), lllllt,lIllL'd .:: \\'hill' lvll'>, \\'hik till' pn1tl'ill kl'l,l \\'.1'> 7(1 1l1gdl dllLl till' glu­CllSl' kl'l'l \\',1'> ISO Il1g dl l'>l'I'UIll gIUlll'>I' kl'l,1 2S(1 Il1g dl). Spllldl Iluid dlld hl""d lliltun''> 11'1'1'1' "h­t, lIllL'd. 1\ Illiddlv Ilirhilldtl' hl"p'>v 11'.1'> lH'g,IlII'I' Illr ,\ II/ltl' I Ill' Pdtll'llt 11'.1'> ,>tdrtl'd Oil .I n'glllH'1l "I illtr,1\l'1l111l'> gl'llt,llllllI11 dlld \dl1<111l1\'lIl1 (h"l ,Ill'>" III ,1 prl'\'lllll'> hlstllr\' 01 pl'llilrlllll ,1I11'rg\'), 'JIld \\·ithlll 2~ h hiS Illl'llt,ll '>tdtU'> Ill1pn'\l'd IIll'rl'l\d'> 1111 ill1prlll'l'1l11'nt in tl1l' 1Iltl'Il,>it\, 01 tl1l' hVdd,lll1l' llr right l'\'l' pain. I k \\'as rl'll'rrl'd to I nlllrv L:IlI­\'(' rsitv Illl'>pit,ll Illr 11Irtl1l'r l'\,lludtioll ,1Ild trvat­Il1l'n!. :'\ l'U n Hlph th,111l11 111 Igll',ll l'\,l 111 I11,1 t II 111 d I'>lll I'>l'd tlw 11111o\\'ing pllsiti\l' tindlllg'> In tl1l' right l'\'(' rl'­duced ViSU,11 ,1l'uitv (2(L il)), ~ 111111 ll\ d\i,lI prt1p­tllsis, ll111dl'ratl' edl'llla III thl' uppl'r ,1nd Illll'l'r lids, p.Hesis III ,1ddudilln ,1Ild I'll'\dtioll 1"llh ,1 slugpshll' rl',lltivt' :I IllIl1 pll pil. ,1Ild IIpht h,111ll1 I­sCllpic signs III ll1ild llptic di'>c l'lklll,) Il'It l'\'(' \i­sual Sl'nSllrV and ll10tllr tl''>ting g,l\l' norlll,ll rl'­suits. Thl'rl' \\'l'rt' nll llrbit,11 bruits. Anl1ther Clllllplltl'd tllll111gr,lphic '>C,ln 01 tht' head and llrbits (Fig. I) disl!llSt'd l'\llphth'llnlll'> III the right gillbe, \\'ith ,1 h,1111 III pnibulb'H inlTea'>ed attenuatil1n and l1p,Kitic,ltilln III thl' ,1d',lcl'nt dh­1ll11id and splwnllid sinusl's. The right C,l\'t'rnllllS sinus appe.Hed abnl1rlllal. cl1lllp.Hl'd \\'ith the It'lt one. A sagittal renlnstrudil1n 111 thl' ,1\1,11 Clllll-pUll'd tlllllographic sections (Fig, 2) displayed bon\' l'rusi"n III the anterior and posterior walls of t hI" spill' n" ids inus, c II n sis tl' n t wit h pos sibIe '>plwnoid o'>tl'oll1\Tlitis. I Ill' lOll1billl'lf clinical and computed tom0­gr, lphir abllllrlll,llitil'S strunglv suggested unilat­vrdl '>l'ptll ld\TfllllllS '>inu'> thrumbllsis with mild "rbil,d ll'lluliti'> B,l'>l'd on the result of the blood lulturl''>, \\'hlch grl'\\' Stnpt(l«(I«uc, interllledius, the .Illllhllltil rl'gl1l11'n \\',lS ch,1I1ged to include intrave­n" lI'> \dnUIIll\'lln, ritampln, and metronidazole. l )\"1' till' nl'\t 11'11' days the patient's condition im­prt '\l'd Rl'pl',l t cui tures of the blood, nasaL and '>Inu'> C,)I'ltil''> \\'l'fe negative. ;\ digital orbital ve­nllgr, lm (fig :I) re\'ealt-d nonfilling l1f the right 01'­bit, ll \t'ln,> ,1Ild C,)I'l'rnou'> sinus. The patient \\'as lllalntall1l'd lIn till' regimen 01 parenteral antibi­otil''> lor an ,1ddIllllnal 2 Il'lTKS and fully reco\,­l'rl'd DISCCSSION I'rl'\'ll'U'>h rtoporlt'd C,he'> 01 unilateral cav­l'rnllUs '>Inu'> thfllmbll"is \\'t're primarilv docu­nwnted rdrtl'>pt'di\'elv, using clinIcal criteria (.f,8); onll' a It'll' ca'>t''> h,)I'e been prll\'en at autl1psv (2), L'nlortun,ltL'lI, mal1\' "lmil.Hitil's e\.ist between the clinical pldurt' III ul1llateral septic ca\'ernl1US sinus thrllmbllsl'> ,1I1d llrbital celluliti", and it is therefore dilticult tll distinguish tl1l'm llll clinic,ll grounds aillne (.f), Because these t\\'ll cllllditillns-septic FIG. 1, An aXial contrast-en­hanced computed tomo­graphiC scan, uSing 1,5-mm slices, demonstrates soft tissue Within the posterror recesses of the ethmoidal sinuses as well as the sphenoid sinus (curved arrow) There is bony destruction of the walls of the posterror ethmoid air cells as well as the anterior wall of the sphenoid sinus (arrow), Soft tissue density is seen ex­panding and filling the right cavernous sinus (arrowhead), The lateral wall of the right cavernous sinus is convex, Proptosis of the right globe and increased peribulbar at­tenuation is identified, CAVU{N( )US SINUS 11/1,( Itv1H( ISIS 37 FIG. 2. A midline sagittal re­construction from the 1.5-mm axial computed tomographic sections was obtained using a bone review window. Soft tissue filling the sphenoid sinus (arrows) and partially filling the posterior ethmoidal sinuses (curved arrow) is dem­onstrated. Bony destruction (arrowheads) IS Identified In the sellar floor and clivus. Can'rnL)US sinus thrombosis ,1nd l)rbital cellulitis­\,' arrant different antibil)tic regimens, the diag­nL) stic \\"L)! kup must include additional im'estiga­ti\' l~ procedures. BdL)re c,mlputed tomograph~.. was av,lilable, L1r­bital wno);raphy \\'as primarily used for the evalu­ation of the orbit and caverl1L)US sinus (tJ-ll). The radiographic features L)f \'enous thrombosis in­cluded one or more of the fL)lIowing: (a) deformity of the ca\'ernous sinus; (b) intraluminal filling de­fects; (c) an atvpical venous L)uttlOW pattern; (d) unusually slow clearing of the contrast medium from the ca\'ernous sinus; and (e) the develop­ment of collateral venous channels. ;'\;arrow, collimated, contrast-enhanced com­puted tomographic scans with reformated images in the coronal, axial, and sagittal planes have also proven to be valuable diagnostic procedures in these cases (12,13). Proper imaging technique is critical. Tomographic sections should include ei­ther overlapping 5-mm slices or nonovt'rlapping l.j-mm slices. While drip infusion of the contrdst medium is usually adequate for most cranial com­puted tomographic scanning, visualization of till' cavernous sinus requires larger doses of contrdst medium. Combining a rapid intravenous (bolus) infusion with a continous drip of contrast medium clearly delineates the boundary of this large venous structure. Reportedly positive computL'd tomographic findings in cavernous sinus throm­bosis (12,13) include decreased L'nhancenlL'nt ,1I1d a filling defect of the cavernous sinus, with convex bOWing of the lateral wall of the sinus. Our p,l­tient's computed tomographic scan W,lS sugges­tive of unilateral septic cavernous sinus throm­bosis, with evidence of sphenoid ostt'omyelitis. The computed tomographic scans illustratL'd the anatomic route by which the parandsal sinus in­fection spread to the blood, causing septic throm-bosis L1f the adjacent caVL'rnllUS "inus a-. well as systemic symptoms. Digital orbital venography was utilized instead of conventional orbital vel1l\graphv in this case since it required less contrast dye and was easier to accomplish. Our decision to subject the patient to this procedure was based upon a need to make the diagnosis and proceed with the most appro- FIG. 3. An anteroposterior view of a digital orbital venogram, with the patient compressing the facial veins with his fingers (outlined in black). is shown. The left finger compresses the angular veins and is positioned somewhat more superiorly than the right finger to decrease the amount of contrast medium flowing in the retro-orbital region on the asymptom­atic side The right finger occludes only the facial veins on the symptomatic Side. This study demon­strates filling of the left (asymptomatic) cavernous sinus (curved arrow) and nonfilling of the right (symp­tomatic) cavernous sinus. 38 tvl, S, I/I\NDI\CI\ IJ At. pri,ltt' rours,' lit ,1I1tibilltil tlll'r,lpv, We felt th"t the p,lti,'nt's signs III dinil,ll il11prllVl'nll'nt Illwl'rl'd till' risks III sl'psis lrum this pn1Cl'durl' (14), lhl' digit,,1 \','nllUS stud\' (hg, .I) dir"lliv visu.lli/l'd the nllninvlllved Il'lt l.l\','rl1l1US sinus ,'nd shllwl'd dl'.H l'vid"lll'l' III ,1 right l-.l\','rJllllIS sinus thnll11­bosis, We b,'li,'vl' th"t p,lti,'nts presenting with the SVl11ptlllllS ,'nd signs lit lIrbit.ll ll'lIulitis llr uni/,lt­,' 1',1/ Sl'ptill,l\','rnllus sinus thrlll11bllsis shlluld un­dl'rgll cr,lni"I-orbit,llllll11pukd t0I1111gr,'phil Sl,ln­ning ,llld possibly digit"lorbit,ll \'l'nogr,'phv, Our p,ltient h,'d p,1I1sinusitis, p'lssiblt' sphenoid osll'o­I11velitis, positive billod lulturl's, and a r,lpidlv 1,1­\' or,lbll' response tll ,1Iltibilltil tlll'rapV'-,lll lit ",hidl C,ln bt' seen with either orbit,ll ll'lIulitis or septic caverJlllUS sinus throl11bosis, Utili/ing dig­ital venous il11aging techniques, we dearlv identi­fied orbital vein and CaVerllllUS sinus thrornbllsis behind the right eve, allowing us tll explain the clinical findings and to pres,'ribe ,1 l1111r,' specific treatment. We believe this tll be the first reported case tlf unilateral Sl'ptiC ca\','rIl0US sinus throl11­bosis diagnosed bv digit"lllrbital vl'nogr,'plw, REFERENCES Yarrington. CT.. C\l\'l'rn{lu ...... 'IlU .... thn)n)b~''''l'''' rt·\·, .... Jtl,d Pn',-, R St''-, ,\ Jed, 70: 4~n-4;</, 1'177, 2, Ilruwn, /,,: SeptiC Cd\'ernou~ thrumbusis, BIII/, /O""S HopkillS 11"'1" 109: 01'-75, 1%1. Kn,lpp, II,' Ueber Vl'r~lopfund dl'r Bluigefas~edes Auges, Albre,'ht Von Cr,lL'fL>~ Arch, I\lill Exp, Op"tlltlll1lol. 18: 2117-2;', 11'01' 4 l'r1n', D, lI,lnll'rl.tt, S, H" dnd Richards, D .. Cavernous ~1I1l" lhrumbo~i~ 'lnd orbit,ll cellulitis, SOlltil. ML'd, /. 64: 124~-1247, /'171 " W"tter~, E. (, W"II,u, r II" lIil,'~, D, A" and Michaels, 1<, II Acute orblt,1I cl'lIl1liti~, A r,-" , 01'''1/111111/01. 94: 7H;-7HH, )Y,n h 1\kAIil'n, r 1\1, 'lnd Shd\\', R E Cavernous sinus throm­bophll'blti' 1\ "l~" du,' to a penllillin-resislant organism, I~I I '>lIr" -l0: 4'1-;2, 'Y~2 / "hdl\', R, E.. (,l\'l'rn"u, 'lnu~ thrumbuphlebitis: a re\'ie\\', H' I 511,', -l0: 40-4H, IY~2 X (,n.\'t', \\' ~, "''Ptle ,lnd 'l,,'ptlC tl'pes oi thrombosis of the l,l\'t'rn"u, ~JnL!' :11"" UI,'/,In/II,'\"1. 24: 29-50, 1936, 'I r"rn,,\\, K Ill'ilr,lg lur dngH.grdphischen diagnostik der bl,InJc'n thr"mb",,' Jl'~ 'InU' (,lH'rnOU5, Rlld",ltlXc 11: 405, IY7! III S"t'g,'r, j ~,(,dbfll'h"n, T, 0 .. GJannotta, 5, L, and Lotz, /' R, Can.tld'l,l\'e-rn"u' 'InU' t!'tulas and \'enous throm­blO~ i" A/II I ,\','urw"dllli 1: 1-l1-141:1, )980, 11 Hnsmar, G, and Bn,mar j Thrumbusls of the intraorbital Ie-In, dnd (,l\','rn"u, 'InU' :111,/ I~'I",,'I, [DIrlXllj (S/tl,-kll.) 18: 14~-I;~, J47~ 12 Klinc', L H, "\11-.,,[, 1 D, P,,,!. \1 ,I D, and \'itek, j, j,: fh,,: l,H-l'rnpu ........ lrlU ... A (lIn'putl·d h1mographll: ~tudy . ..\ 1.\ 1\ 2: 2</4-111;, )4xl 11 Ll'\\, D, S,'uth\\ Ilk F " , \I"ntg"mc'n', \\' \\', \\'eber, A, L.. dnd H.ll-.er, A 5 "p,'n"ld 'InuSllJ" a rene\\' of thlrt\ (a,,·, ,\ '-'I,! I ,\f,'" 309: 114</-) I ;4, lYx3, 14, Rltchil', \\ C \1, L\nc'h, r R, ,lnJ 5tc'\\ar!. G, J, The diecl "f (utHr,hl mc:dld (In n,'rm,ll and intl'ln1t'd canine \·t'ln~. .-\ .... (~lnnln.~ ~lnJ tr~ln ...ml ........ illn l,lectr(ln mi(rl)~Cl)pic ,tu,h 111,',',1 1~"dl,'1 9: 444-4:;~, 14;-4 [CLorbitalinfections]