Bilateral septic cavernous sinus thrombosis, congestive orbitopathy, and ischemic optic neuropathy

Utility of standard diffusion-weighted magnetic resonance imaging for the identification of ischemic optic neuropathy in giant cell arteritis

This study assessed diffusion abnormalities of the optic nerve (ON) in giant cell arteritis (GCA) patients with acute onset of visual impairment (VI) using diffusion-weighted magnetic resonance imaging (DWI). DWI scans of GCA patients with acute VI were evaluated in a case-control study. Two blinded neuroradiologists assessed randomized DWI scans of GCA and controls for ON restricted diffusion. Statistical quality criteria and inter-rater reliability (IRR) were calculated. DWI findings were compared to ophthalmological assessments. 35 GCA patients (76.2 ± 6.4 years; 37 scans) and 35 controls (75.7 ± 7.6 years; 38 scans) were included. ON restricted diffusion was detected in 81.1% (Reader 1) of GCA scans. Localization of ON restricted diffusion was at the optic nerve head in 80.6%, intraorbital in 11.1% and affecting both segments in 8.3%. DWI discerned affected from unaffected ON with a sensitivity, specificity, positive and negative predictive value of 87%/99%/96%/96%. IRR for ON restricted diffusion was κ_inter = 0.72 (95% CI 0.59–0.86). DWI findings challenged ophthalmologic diagnoses in 4 cases (11.4%). DWI visualizes anterior and posterior ON ischemia in GCA patients with high sensitivity and specificity, as well as substantial IRR. DWI may complement the ophthalmological assessment in patients with acute VI.

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.

Atypical Cavernous Sinus Thrombosis: A Diagnosis Challenge and Dilemma

Cavernous sinus thrombosis (CST) is an ocular emergency because of its devastating effect and it is prone to cause serious complications. Diagnosis of cavernous sinus thrombosis is a challenging task despite medical advancement. Efforts to promptly diagnose and initiate treatment require a high index of suspicion and a deep understanding of the disease. Unfortunately, patients suffering from CST may not always present with typical symptoms, thus making diagnosis all the more challenging. We would like to describe a 22-year-old man who presented with atypical symptoms and radiological presentations of CST. The patient was admitted and treated in our institution with full recovery demonstrated after the treatment.

Invasive Fungal Sinusitis Presenting as Acute Posterior Ischemic Optic Neuropathy

Invasive fungal sinusitis causes painful orbital apex syndrome with ophthalmoplegia and visual loss; the mechanism is unclear. We report an immunocompromised patient with invasive fungal sinusitis in whom the visual loss was due to posterior ischaemic optic neuropathy, shown on diffusion-weighted MRI, presumably from fungal invasion of small meningeal-based arteries at the orbital apex. After intensive antifungal drugs, orbital exenteration and immune reconstitution, the patient survived, but we were uncertain if the exenteration helped. We suggest that evidence of acute posterior ischaemic optic neuropathy should be a contra-indication to the need for orbital exenteration in invasive fungal sinusitis.