[Meningitis and septic sinus thrombosis in connection with otitis media]

This is a case report of a 30-year-old female, who presented to the emergency department with headache, nausea and neck pain after five days of otitis media. After lumbar puncture, CT and MRI the patient was treated for meningitis with initial improvement in the clinical state. After four days she developed contralateral neurological symptoms, and after five days she had a seizure. MR-venography showed thrombosis of the lateral dural sinus with venous cerebral infarction. The treatment of intravenously administered antibiotics, mastoidectomy and anticoagulation is discussed and compared with other cases in the literature.

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.

Anticoagulation for cerebral venous thrombosis with subarachnoid hemorrhage: a case report

OBJECTIVES

To report the success of anticoagulation (AC) treatment in a case of cerebral venous thrombosis (CVT) with subarachnoid hemorrhage (SAH) in view of the limited evidence seen in the literature supporting such a treatment option.

CLINICAL PRESENTATION AND INTERVENTION

A 38-year-old lady with CVT and SAH presented 12 h after the onset of symptoms. AC with low-molecular-weight heparin was started 4 days later, when the repeated brain CT showed regression of the SAH. Heparin was changed to warfarin, and she was asymptomatic over a 12-month follow-up period.

DISCUSSION

In a limited number of small studies, AC has been found to be beneficial for cases of CVT with hemorrhagic complications. The proper time to start AC in such cases was not clearly defined, and a delay of 4-33 days was observed after the onset of symptoms. In cases of spontaneous intracranial hemorrhage (ICH) in general, active bleeding is usually confined to the first 6 h, and chances of hematoma enlargement are higher in the first 24 h. On the other hand, it has been advised to rule out a coincidental vascular malformation and to radiologically confirm regression (or at least non-progression) of the ICH before starting AC.

CONCLUSION

AC for cases of CVT may remain beneficial in the presence of SAH. The time to start AC for CVT with hemorrhagic complications is unclear; however, AC was successful when given 4 days after the onset of symptoms in our case. It may be wise to repeat CT after at least 24 h from the onset of symptoms (to confirm regression or at least non-progression of the ICH) before starting AC. It may also be prudent to perform magnetic resonance angiography, or digital subtraction angiography to rule out a coincidental intracranial aneurysm before AC.

[Local thrombolysis of sinus thrombosis]

A 16-year-old girl was diagnosed with widely distributed dural sinus thrombosis (DST) and a haemorrhagic infarct in the left parietal lobe. Despite of heparin treatment, pronounced aggravation of symptoms was observed. Through a femoral vein approach a micro-catheter was advanced into the superior sagittal sinus and rt-PA was infused slowly, directly into the thrombus over 24 hours. A follow up angiogram showed recanalisation of sinus. The patient recovered almost completely, with only few remaining cognitive symptoms. This treatment remains experimental, but should be kept in mind for DST-patients unresponsive to heparin treatment.

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.

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.

Conservative nonsurgical treatment of a child with otogenic lateral sinus thrombosis

We present the case of a 5-year-old boy with otogenic lateral sinus thrombosis that developed after acute mastoiditis, with no prior ear disease. He was treated with myringotomy and antibiotics alone, with no surgical intervention. This approach was followed owing to his good general condition, the prompt response to the antimicrobial treatment, and no evidence of suppurative disease. Sinus recanalization was evident on the follow-up computed tomography 4 months later. We believe that in selected cases of otogenic lateral sinus thrombosis, secondary to an acute ear infection with early response to antibiotic therapy, conservative treatment may be considered and surgical intervention may be withheld.

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.

A caution regarding the use of low-molecular weight heparin in pediatric otogenic lateral sinus thrombosis

Lateral sinus thrombosis (LST), a rare complication of otitis media, is managed by antibiotics, surgery and anticoagulation. Traditionally, post-operative anticoagulation has been achieved by intravenous unfractionated heparin followed by oral warfarin. Fractionated, or low-molecular weight heparin derivatives (LMWH) have been introduced recently. There has been minimal literature to date regarding their use for the management of LST. We present use of the LMWH enoxaparin (Lovenox) for otogenic LST in two children, both of whom experienced hemorrhagic complications. On this basis and in the context of a literature review, we urge caution when using LMWH for pediatric otogenic LST.

Thrombose veineuse cérébrale aseptique et tuberculomes cérébraux compliquant une miliaire tuberculeuse pulmonaire

INTRODUCTION

Severe pulmonary tuberculosis may be complicated by deep vein thrombosis due to a state of hypercoagulability.

OBSERVATION

We report a case of pulmonary miliary tuberculosis associated with cerebral venous thrombosis and multiple intracranial tuberculomas. A 65-year-old woman developed a confusional syndrome one week after starting treatment for pulmonary military tuberculosis. Neuroimaging reveals a thrombus in the right lateral sinus and multiple silent intracranial tuberculoma.

CONCLUSION

The patient was given anticoagulants and fully recovered.

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.

Lateral sinus thrombosis after untreated otitis media. A clinical problem--again?

Antimicrobial agents have greatly reduced the incidence of intracranial complications of infections of the middle ear and mastoid. Too many prescriptions and overconsumption of antibiotics when otitis media is suspected has caused resistance to many antibiotics, leading to a pronounced and justifiable desire to reduce the widespread excessive use of antibiotics. The possible untoward consequences of a too restricted antibiotic policy, however, is illustrated by the following case of a 14-year-old boy who, after non-treatment of an ear infection, fell ill with one-sided headache and vomiting caused by a lateral sinus thrombosis. After intravenous treatment with antibiotics, anticoagulants and ventilation of the middle ear, the infection was cured without complications. This case calls attention to the symptoms of otitic complications arising outside the temporal bone. The physician must always bear in mind the possibility of an unusual event. The general treatment of endocranial complications is outlined, giving details of the treatment given in this special case. We stress that one should not be too cautious in prescribing antibiotics in otitis media.