Fig 6 - available via license: CC BY-NC-ND
Content may be subject to copyright.
Axial post contrast T1W image shows: Thrombosed right sigmoid sinus and IJV (yellow arrow), in comparison to the normal left side (red arrow).
Source publication
Purpose
To determine the role of Contrast enhanced MRI (CEMRI) in the evaluation of Cavernous sinus thrombosis (CST).
Method
The study included 7 patients with an imaging diagnosis of cavernous sinus thrombosis. A retrospective analysis of Contrast enhanced MRI of 9 affected cavernous sinuses and a control group of 7 patients (14 cavernous sinuses...
Context in source publication
Context 1
... enhancement was seen to extend along the pituitary (one patient), the petrous apex, sphenoid and clivus (one patient) and along prepontine, premedullary and perimesencephalic cistern(one patient). IJV was seen to be thrombosed in 2 patients while sigmoid sinus showed evidence of thrombosis in one. (Fig. 6) A frontal subperiosteal abscess was seen in one patient, while enhancing collections over the maxillary bone were seen in another patient. patients with CST (Mean ± SD; 3.5 mm ± 0.9 mm) and control subjects (4.6 mm ± 0.44 ...
Similar publications
One of the most serious/potentially fatal complications of transsphenoidal surgery (TSS) is internal carotid artery (ICA) injury. Of 6230 patients who underwent TSS, ICA injury occurred in 8 (0.12%). The etiology, possible treatment options, and avoidance of ICA injury were analyzed. ICA injury occurred at two different stages: (1) during the expos...
Citations
... Thanks to the development of the pharmaceutical industry and the appearance of new antibiotics, mortality has decreased dramatically. [22] To demonstrate thrombosis as a direct method, CT (computed tomography) and/or MRI (magnetic resonance imaging) are necessary. Non-contrast computed tomography most often reveals swelling, dilatation of the superior and inferior ophthalmic veins, and bulging of the lateral edges of the cavernous sinus. ...
The neurosurgical literature shows that the effectiveness of the main sinus outflow in its main function depends on access to the anatomy and pathology in the presellar area and the development of neuroimaging methods. The pathology of the cavernous sinus is often revealed in imaging tests, which are often accompanied by other tests unrelated to the cause. Tumors located within the cavernous sinus pose a significant challenge for surgeons. Although it is often possible to decide to opt out, it is possible. Not only tumors can be located in the cavernous sinus and affect placement in any structure. The aim of this work is to raise awareness of pathological conditions within the cavernous sinus. Methods: Selected articles from Pubmed and specialist textbooks were analyzed in detail. We focused on selected pathological conditions occurring within the cavernous sinus, which a doctor may often encounter in his clinical work. Conclusion: The cavernous sinus is a place where tumors and other pathologies arise. The development of imaging diagnostics allows neurosurgeons to more precisely determine the place within the sinus that has changed, and access to it is quite a challenge. Numerous observations of clinical conditions are increasingly a source of knowledge that can provide a therapeutic trial, but also speed up the detection of potential changes.
... SOV diameter was measured perpendicular to the SOV on coronal images on the closest slice to the rear of the globe. Proptosis was defined as a globe protrusion of more than 21 mm anterior to the interzygomatic line at the level of the lens on axial images ( Fig. 2f; [12]). Ischemic stroke subtypes were categorized according to TOAST criteria classification: 1) large artery atherosclerosis, 2) cardioembolism, 3) small vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology [13]. ...
... Presence of cavernous sinus thrombosis can impair the drainage of blood from the SOV, leading to engorgement or thrombosis of the SOV, thus it can be considered as an indirect sign of cavernous sinus involvement [12]. In line with this fact, our study showed that diameter of SOV in patients with stroke is larger than patients without stroke. ...
... Also, increased signal intensity of SOV on spin echo MRI sequence was more prevalent in patients with stroke. This finding can be due to blood stasis and possible thrombosis in SOV that may be sign of more extensive involvement of cavernous sinus that result in stroke [12,17]. ...
PurposeThe aim of this study was to compare clinical, neuroimaging, and laboratory features of rhino-orbito-cerebral mucormycosis (ROCM) in COVID-19 patients with and without ischemic stroke complications.Methods
This observational study was conducted between August and December 2021 and 48 patients who had confirmed ROCM due to COVID-19, according to neuroimaging and histopathology/mycology evidence were included. Brain, orbit and paranasal sinus imaging was performed in all included patients. Data pertaining to clinical, neuroimaging, and laboratory characteristics and risk factors were collected and compared between patients with and without ischemic stroke complications.ResultsOf the patients 17 were diagnosed with ischemic stroke. Watershed infarction was the most common pattern (N = 13, 76.4%). Prevalence of conventional risk factors of stroke showed no significant differences between groups (patients with stroke vs. without stroke). Cavernous sinus (p = 0.001, odds ratio, OR = 12.8, 95% confidence interval, CI: 2.3–72) and ICA (p < 0.001, OR = 16.31, 95%CI: 2.91–91.14) involvement was more common in patients with stroke. Internal carotid artery (ICA) size (on the affected side) in patients with ischemic stroke was significantly smaller than in patients without stroke (median = 2.4 mm, interquartile range, IQR: 1.3–4 vs. 3.8 mm, IQR: 3.2–4.3, p = 0.004). Superior ophthalmic vein (SOV) size (on the affected side) in patients with stroke was significantly larger than patients without stroke (2.2 mm, IQR: 1.5–2.5 vs. 1.45 mm IQR: 1.1–1.8, p = 0.019). Involvement of the ethmoid and frontal sinuses were higher in patients with stroke (p = 0.007, OR = 1.85, 95% CI: 1.37–2.49 and p = 0.011, OR = 5, 95% CI: 1.4–18.2, respectively). Patients with stroke had higher D‑dimer levels, WBC counts, neutrophil/lymphocyte ratios, and BUN/Cr ratio (all p < 0.05).Conclusion
Stroke-related ROCM was not associated with conventional ischemic stroke risk factors. Neuroimaging investigations including qualitative and quantitative parameters of cavernous sinus, ICA and SOV are useful to better understand the mechanism of stroke-related ROCM in COVID-19 patients.
... The proposed neuroradiological features were prepared after a thorough literature review. [14][15][16] CSS was classified using Ishikawa classification [Supplementary file-Annexure 3]. [12,14] Clinical examination, procedures, and investigations were done using recommended government guidelines for COVID-19. ...
... In our study, direct qualitative neuroimaging features in CSS-positive group included abnormal signal intensity and convexity of lateral wall of cavernous sinus as reported previously [ Table 3]. [14,15] Cavernous sinus thrombosis and internal carotid artery involvement were more as compared to the previous studies. [16,18,24] These vascular complications were due to spread of infection through adjoining orbits or sinuses or veins and hypercoagulable state with COVID-19. ...
Objective
With coronavirus disease 2019 (COVID-19) pandemic across the world, there had been an exponential increase in rhino-orbito-cerebral mucormycosis (ROCM). Extension of infection to cavernous sinus leads to cavernous sinus syndrome (CSS). This study aims to describe incidence, clinicoradiological profile, and outcome of CSS positive along with comparative analysis of CSS negative COVID-19-associated ROCM.
Material and Method
This was a prospective and observational study conducted from May 1, 2021, to July 31, 2021. Subjects included ROCM with active or recovered COVID-19 (past 6 weeks) and were categorized and staged. CSS was defined as involvement of two or more of third, fourth, fifth, or sixth cranial nerve with one each direct and indirect qualitative neuroradiological features. Clinicoradiological features of CSS-positive and negative COVID-19-associated ROCM groups were compared.
Results
Incidence of CSS with COVID-19-associated ROCM was 28%. Mean age of subjects was 44 ± 15 years with 60% being males and 73% were proven ROCM. Significant differences seen across the CSS-positive and negative groups were ocular, nasal, and cerebral findings including eyelid and periocular discoloration, ptosis, proptosis, ophthalmoplegia, nasal discharge, mucosal inflammation, and fever. Oculomotor, trochlear, and abducens nerves were significantly involved more in CSS-positive group. Significant radiological findings across two groups included indirect features in orbit, nose, and paranasal sinuses along with direct features in cavernous sinus. Surgical intervention was more common in CSS-positive group. Mortality in CSS-positive group at 8–24 weeks was 13 and 27%, respectively.
Conclusion
Extension of ROCM to CSS was more common in young males in advanced stages of proven ROCM with concurrent COVID-19. CSS-positive group had significant difference in clinicoradiological features involving orbit, nose, paranasal sinuses, and central nervous system as compared to CSS-negative group. This study highlights the need to develop an objective scoring system considering clinical and radiological features for diagnosis of CSS with COVID-19-associated ROCM.
... In addition to the above-mentioned signs, contrastenhanced CT/MRI, shows the presence of asymmetric filling defects, thrombosis in the superior ophthalmic vein, other venous tributaries, dural venous sinuses, and cerebral veins. 18 In our case, a CT scan was able to diagnose the thrombus in the cavernous sinus by showing low-intensity cavernous sinus, with bulging of its lateral margins, dilation of the ophthalmic veins, and bilateral exophthalmos more marked in the left eye. ...
Otogenic cerebral sinovenous thrombosis is an intracranial complication secondary to otogenic disease; it is rare but could be a life‐threatening condition. Its management is always challenging. This study aimed to focus on clinical features, on diagnosis of this pathology and to review the most controversial aspect of management of otogenic cerebral sinovenous thrombosis. We reviewed retrospectively 10 inpatients treated with cerebral sinus thrombosis secondary to otitis between 1995 and 2020. Ten inpatients (eight males and two females) with ages ranging from 11 to 77 years were diagnosed with ontogenesis sinus thrombosis. The most commonly reported symptoms were headaches and otalgia. Five patients had mastoiditis, and 7 of the 10 patients had other concurrent complications: cerebellar abscess (three patients) and extradural empyema in two patients, retropharyngeal abscess in one patient, and meningitis in one patient. All patients were treated with broad‐spectrum antibiotherapy, anticoagulation was used to treat nine patients, and surgery was required in nine patients. Nine patients had satisfactory resolution of their symptoms, but one patient had sequel as permanent loss of visual acuity. Because of the inconspicuous clinical presentation, and the probability of a fatal evolution, suspicion is essential for a proper diagnosis and suitable treatment.
... There are direct and indirect findings of cavernous sinus extension, and imaging in the coronal plane provides further information (68). Direct findings include destruction of the bone floor at CT (78%, 32 of 42), hypointense lesions in the cavernous sinus at T1-and T2-weighted MRI, and enlargement and expansion of the cavernous sinus with bulging lateral walls on both coronal CT and MR images (Fig 12) (6,39,68). ...
... There are direct and indirect findings of cavernous sinus extension, and imaging in the coronal plane provides further information (68). Direct findings include destruction of the bone floor at CT (78%, 32 of 42), hypointense lesions in the cavernous sinus at T1-and T2-weighted MRI, and enlargement and expansion of the cavernous sinus with bulging lateral walls on both coronal CT and MR images (Fig 12) (6,39,68). Loss of flow voids, with restricted diffusion at diffusionweighted MRI, suggests cavernous sinus thrombosis. Indirect findings include narrowing of the ICA flow void in the cavernous sinus and dilatation and/or subsequent thrombosis of the superior and inferior ophthalmic veins (68). ...
... Loss of flow voids, with restricted diffusion at diffusionweighted MRI, suggests cavernous sinus thrombosis. Indirect findings include narrowing of the ICA flow void in the cavernous sinus and dilatation and/or subsequent thrombosis of the superior and inferior ophthalmic veins (68). Cavernous sinus extension is usually accompanied by sphenoid sinusitis and/or an orbital apex lesion, and it mimics a sellar mass. ...
Invasive fungal rhinosinusitis (IFRS) is a serious infection that is associated with high morbidity and mortality rates. The incidence of IFRS has been increasing, mainly because of the increased use of antibiotics and immunosuppressive drugs. Rhino-orbital cerebral mucormycosis has recently reemerged among patients affected by COVID-19 and has become a global concern. The detection of extrasinus involvement in its early stage contributes to improved outcomes; therefore, imaging studies are essential in establishing the degree of involvement and managing the treatment properly, especially in immunocompromised patients. The common sites of extrasinus fungal invasion are the intraorbital, cavernous sinus, and intracranial regions. Fungi spread directly to these regions along the blood vessels or nerves, causing devastating complications such as optic nerve ischemia or compression, optic neuritis or perineuritis, orbital cellulitis, cavernous sinus thrombosis, mycotic aneurysm, vasculitis, internal carotid arterial occlusion, cerebral infarction, cerebritis, and brain abscess. IFRS has a broad imaging spectrum, and familiarity with intra- and extrasinonasal imaging features, such as loss of contrast enhancement of the affected region, which indicates tissue ischemia due to angioinvasion of fungi, and the surrounding anatomy is essential for prompt diagnosis and management. The authors summarize the epidemiology, etiology, risk factors, and complications of IFRS and review the anatomy and key diagnostic imaging features of IFRS beyond the sinonasal regions.
... On the other hand, cavernous sinus (CS) drains blood from the facial vein, and the ophthalmic veins into the basilar plexus, and it is closely related to the sphenoid sinus. Therefore, infection, or trauma of the paranasal sinuses or any of the anatomic structures drained by the cavernous sinus, including the mid-face, orbit, pharynx, oral cavity, and ear, may predispose to CST. 7 Prior to the COVID-19 era only 200 cases were reported in literature 8 and approximately 0.2 to 1.6 CST cases per 100,000 were reported yearly 9 with an increased susceptibility in diabetic or immunosuppressed patients, 10 and a strong association with the development of mucormycosis as an invasive and aggressive infection in COVID-19 patients. 11 There is limited data on the changing trends in epidemiology of CST in the COVID-19 era in terms of prevalence, predisposing factors and adverse outcomes. ...
Background:
A heavy burden of cranio-maxillofacial complications may be encountered in corona virus disease-2019 patients due to the associated coagulopathy and inflammatory consequences of the disease. This study aims to describe clinical and radiographic features of these complications in 256 patients who developed 1 or more of the following complications: cavernous sinus thrombosis, osteomyelitis or necrosis of the jaws.
Methods:
Clinical assessment of cranial nerve function and general clinical assessment were performed. Imaging techniques used were multi-slice computed tomography, magnetic resonance imaging, and MRI with contrast enhancement.
Results:
Thromboembolism of brain and facial blood vessels were associated with inflammation and necrosis. Multi-slice computed tomography/MR angiography showed thrombotic occlusions of the internal carotid artery in the area of the cavernous sinus, and in the ophthalmic veins. Cavernous sinus thrombosis was attributed to coagulopathy and, inflammation of the paranasal sinuses, especially sphenoiditis. A noticeable increase in the size of the cavernous sinus was detected. Compression of the cranial nerves in the cavernous sinus (CS) region causes dysfunction and pathology in the corresponding regions.
... Cavernous sinus thrombosis may be initially explored with non-contrast CT of the head which can show subtle abnormalities such as bulging of the lateral margins of the cavernous sinus, heterogeneous filling defect, and engorgement of the superior and/or inferior ophthalmic veins. In addition to the above-mentioned signs, contrast-enhanced CT/MRI, shows the presence of asymmetric filling defects, thrombosis in the superior ophthalmic vein, other venous tributaries, dural venous sinuses, and cerebral veins (18). In our case, a CT scan was able to diagnose the thrombus in the cavernous sinus by showinglow-intensity cavernous sinus, with bulging of its lateral margins, dilation of the ophthalmic veins, and bilateral exophthalmos more marked in the left eye. ...
We aimed to focus on clinical features, on diagnosis of this pathology and to review the most controversial aspect of management. We reviewed 10 in patients between 1995 and 2020. All patients were treated with broad-spectrum antibiotherapy, anticoagulation in 9 patients, and surgery required in 9 patients.
... This is due to the anatomy and venous drainage of the face that generate probability of a multidirectional venous flux 7,2 . Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are the most frequently performed exams to arrive at diagnosis, which may help in the early recognition of the disease and, possibly, in a better prognosis 8,9 . The management of the infection consists in the control of the disease through medicines that sensitize the causative agent and prevent the spread of infection 1 ...
... It is visualised as restricted diffusion along the affected nerve (Figs. 6 and 7), usually without any enlargement, altered T2/STIR signal intensity or post contrast enhancement [10,11]. • Perineural spread. ...
Rhino-orbito-cerebral mucormycosis (ROCM) has regained significance following its resurgence in the second wave of the COVID-19 pandemic in India. Rapid and progressive intracranial spread occurs either by direct extension across the neural foraminae, cribriform plate/ethmoid, walls of sinuses, or angioinvasion. Having known to have a high mortality rate, especially with intracranial extension of disease, it becomes imperative to familiarise oneself with its imaging features. MRI is the imaging modality of choice. This pictorial essay aims to depict and detail the various intracranial complications of mucormycosis and to serve as a broad checklist of structures and pathologies that must be looked for in a known or suspected case of ROCM.
... Other features like narrowing of the carotid artery, carotid arterial wall enhancement, and other intraparenchymal abnormalities like cerebral infarcts, empyema, and meningitis may also be seen. 22 Cerebral angiography may further reveal vascular occlusion, aneurysmal dilatation, or filling defect. 23 Pulmonary mucormycosis (PM) most commonly presents as lobar/segmental consolidation. ...
... Other vascular findings may include pseudoaneurysm formation and abrupt termination of a pulmonary artery branch. 22 While most fungal pneumonia shows nonspecific signs at imaging, the 'reverse halo sign' has been shown to be a specific sign of mucormycosis, occurring in 19-94% of patients with PM. 22,25 It is defined as ground-glass opacity surrounded by a rim of consolidation. The sign can also help distinguish between other fungal pneumonias, particularly invasive pulmonary aspergillosis (IPA). ...
... Other vascular findings may include pseudoaneurysm formation and abrupt termination of a pulmonary artery branch. 22 While most fungal pneumonia shows nonspecific signs at imaging, the 'reverse halo sign' has been shown to be a specific sign of mucormycosis, occurring in 19-94% of patients with PM. 22,25 It is defined as ground-glass opacity surrounded by a rim of consolidation. The sign can also help distinguish between other fungal pneumonias, particularly invasive pulmonary aspergillosis (IPA). ...
Mucormycosis, commonly known as the “black fungus” is recently emerging as a deadly complication in COVID patients in the Indian subcontinent. A growing number of cases are being reported from all over the country, with a majority of the patients either undergoing treatment or having recovered from COVID.
Here, we report three cases of multisystem mucormycosis in COVID positive patients showing, rhino-orbital, cerebral, pulmonary, and genitourinary involvement. The first is a case of a 41-year-old male patient who during his treatment developed left periorbital swelling with ecchymosis and headache. CT and CE-MRI of the paranasal sinuses and brain revealed features of pan fungal sinusitis and subsequent invasion into the left orbit. The second case is of a 52-year-old male patient who after complaining of a severe left-sided hemicranial headache was diagnosed with cavernous sinus thrombosis. The third is of a 57-year-old male patient who presented with left flank pain and dysuria. HRCT (High-resolution CT) chest revealed a thick-walled cavitary lesion, and NCCT KUB (Non-contrast CT of Kidneys, ureters, and bladder) revealed left-sided pyelonephritis. A cystoscopic and microbiological evaluation revealed fungal growth.
In all three patients, a biopsy from the involved area revealed broad aseptate filamentous fungal hyphae suggestive of mucormycosis, which was confirmed on culture.
These are all unusual cases and physicians should be aware of the possibility of secondary invasive fungal infections in patients with COVID-19 infection.
