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1/12. Infratentorial subdural empyema, pituitary abscess, and septic cavernous sinus thrombophlebitis secondary to paranasal sinusitis: case report.

    OBJECTIVE AND IMPORTANCE: Infratentorial empyema, pituitary abscess, and septic cavernous sinus thrombophlebitis are all rare and potentially lethal conditions. The occurrence of all three in a single patient has not previously been described. We present such a case occurring in a young, otherwise healthy man. CLINICAL PRESENTATION: A 26-year-old man with a remote history of sinusitis developed rapidly progressive headache, fever, right eye pain, swelling, proptosis, and visual impairment. magnetic resonance imaging demonstrated diffuse pansinusitis, including sphenoid sinusitis, and extension of inflammation and infection into the adjacent cavernous sinuses, pituitary gland, and posterior fossa. INTERVENTION: Urgent drainage of the ethmoid and maxillary sinuses was performed; pus was not identified. The patient continued to deteriorate clinically with worsening of visual acuity. Computed tomography of the head performed the next day revealed worsening hydrocephalus and an enlarging posterior fossa subdural empyema. Urgent ventricular drainage and evacuation of the empyema was performed, and subsequently, the patient's clinical course improved. The microbiology results revealed alpha hemolytic streptococcus and coagulase-negative staphylococcus species. The patient survived but during the follow-up period had a blind right eye and pituitary insufficiency. CONCLUSION: Paranasal sinusitis can have devastating intracranial sequelae. Involvement of the adjacent pituitary gland and cavernous sinuses can result in serious neurological morbidity or mortality, and retrograde spread of infection through the basal venous system can result in subdural or parenchymal brain involvement. A high index of suspicion and aggressive medical and surgical treatment are crucial for patient survival, but the morbidity rate remains high. Our patient survived but lost anterior pituitary function and vision in his right eye.
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2/12. Variant arteriovenous fistula of the superior sagittal sinus--case report.

    A 57-year-old male presented with a rare variant of dural arteriovenous fistula, located in the wall of an unobstructed superior sagittal sinus. drainage occurred through a cortical vein no longer connected to its parent sinus, which filled up a cluster of transmedullary running veins, one of which was the presumed site of hemorrhage. Arterial blood was supplied via the external carotid artery branches. This type of fistula seriously increases the risk of hemorrhage in the patient and therefore requires complete obliteration. Attempts to embolize the fistula failed. The draining vein was isolated and coagulated resulting in permanent occlusion of the fistula. The fistula probably developed through a process of thrombophlebitis and revascularization via arterioles of the vein rather than previous occlusion of the sinus.
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3/12. superior sagittal sinus and cerebral cortical venous thrombosis caused by congenital protein c deficiency--case report.

    A 47-year-old male receiving anticoagulant therapy for thrombophlebitis in the left leg for several years presented with mild left hemiparesis and ipsilateral hypesthesia. The cause of the thrombophlebitis was still unknown. Magnetic resonance (MR) imaging showed subacute thrombosis of both the superior sagittal sinus (SSS) and a cortical vein in the right cerebral hemisphere. Fluid attenuation inversion recovery axial MR imaging demonstrated these lesions more obviously than conventional T2-weighted axial MR imaging. Right carotid angiography showed a partial SSS filling defect and occlusion of the cortical vein with collateral circulation. Coagulation studies revealed decreases in both protein C activity and antigen levels with normal levels of blood coagulation factors II, VII, IX, and X and protein s activity and antigen. The patient's mother had normal levels of both protein C activity and antigen, but his father had decreased levels. The diagnosis was SSS and cerebral cortical venous thrombosis caused by congenital protein c deficiency. The patient was treated conservatively, and his clinical course was uneventful. His neurological dysfunctions recovered within approximately 3 weeks after the onset. Ten months later, right carotid angiography showed recanalization of the SSS and partial filling of the cortical vein. Anticoagulant therapy has been continued, and no cerebral venous thrombosis has recurred during the 1.5 years after the onset.
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4/12. fever of unknown origin following traumatic brain injury.

    Fever is a common complication of a traumatic brain injury, occurring during both the acute-care phase and the rehabilitation phase of recovery. The aetiology of fever in this population may remain obscure because of the presence of cognitive confusion associated with post-traumatic amnesia interfering with history taking and the difficult physical examination. We present a case where recovery from a traumatic brain injury was complicated by a fever of unknown origin that proved to be secondary to lateral sinus thrombophlebitis. This case emphasises the importance of a thorough knowledge of the differential diagnosis for fever that is unique to the traumatic brain injury population.
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5/12. Septic cavernous and lateral sinus thrombosis: modern diagnostic and therapeutic principles.

    The incidence of both lateral and cavernous sinus thrombophlebitis has been significantly reduced in the antibiotic era. Since septic cavernous sinus thrombosis (CST) is mainly a complication of facial abscesses and septic lateral sinus thrombosis (LST) is almost invariably due to chronic otitis media, both conditions are of clinical relevance to the otolaryngologist. The predominant bacterium in septic CST is staphylococcus aureus whereas in septic LST the bacteriology is very similar to that found in chronic otitis media. The diagnosis of septic CST can be established in most cases after thorough clinical examination, and contrast computerized tomography (CT) using the coronal projection usually confirms the clinical diagnosis. The signs and clinical course of septic LST are non-specific and the final diagnosis rests upon radiological investigations including CT-scan. The treatment of both conditions consists of broad-spectrum antibiotics, including beta-lactamase resistant penicillin in cases of septic CST. Most cases of septic LST also require surgical intervention. Two cases of septic intracranial sinus thrombosis are presented. The need for early diagnosis and treatment of this potentially lethal condition is emphasized.
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6/12. CT observations pertinent to septic cavernous sinus thrombosis.

    The use of high-resolution computed tomography (CT) is described in four patients with septic cavernous sinus thrombosis. In all patients CT findings included multiple irregular filling defects in the enhancing cavernous sinus. Unilateral or bilateral inflammatory changes in the orbital soft tissues were also present. Enlargement of the superior ophthalmic vein due to extension of thrombophlebitis was noted in three patients.
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7/12. Polymicrobial anaerobic septicemia due to lateral sinus thrombophlebitis.

    Continuous polymicrobial anaerobic septicemia was the main manifestation of a lateral sinus thrombophlebitis (LST) in a patient who had a history of chronic otitis media. Five different anaerobic microorganisms were isolated in blood cultures. Three of them were also present in ear cultures. The diagnosis was confirmed at surgery and the patient was successfully treated with moxalactam disodium therapy. This case emphasizes that LST should be considered before polymicrobial anaerobic septicemia, especially if there is a history of chronic otitis media.
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8/12. lateral sinus thrombosis.

    The incidence of lateral sinus thrombophlebitis has been significantly reduced since the advent of antibiotics. This entity is rarely encountered in clinical practice, so a high index of suspicion is essential for early diagnosis and appropriate management. Although uncomplicated dural venous thrombosis carries an excellent prognosis with proper treatment, delay in diagnosis and institution of appropriate therapy may lead to serious, or even fatal, consequences. It is hoped that this case report and discussion will serve to increase the awareness of lateral sinus thrombophlebitis as a potential complication of suppurative otitis media.
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9/12. Bilateral thrombosis of the transverse sinuses: microsurgical revascularization with venous bypass.

    The present paper reports a case of intracranial hypertension secondary to thrombophlebitis of the two transverse sinuses and internal jugular veins in which microsurgical revascularization was attempted. This was carried out by means of a bypass graft inserted between the right transverse sinus and the superficial jugular vein. As early as the first post-operative week, intracranial pressure improved and visual disorders regressed. This type of venous revascularization using microsurgical techniques should contribute to more successful and lasting results in cases of sinus occlusions of thrombophlebitic, traumatic or tumorous origins.
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10/12. Intracranial dural arteriovenous fistulas and sinus thrombosis. Report of five cases.

    Dural arteriovenous fistula and sinus thrombosis are sometimes associated. The relationship between these two conditions remains unclear. thrombophlebitis of the dural sinus may induce a dural fistula. Conversely, thrombophlebitis is sometimes observed in the course of dural fistulas. We report five cases of dural arteriovenous fistulas associated with sinus thrombosis. In three cases, the angiographic and pathological data indicated the responsibility of thrombosis in the occurrence of the fistula. In the others two cases, thrombophlebitis and fistula were simultaneously diagnosed by angiography. However, in one of these cases, the clinical data showed that the fistula probably was a causative factor in the occurrence of thrombophlebitis.
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