Page 933 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

664 PART 5: Infectious Disorders

adequacy of collateral venous drainage. 64,74 Persons with inadequate focus of infection), although, in septic thrombosis of the superior sagit-
collateral flow present with impairment of consciousness, focal or gen- tal sinus, there may be findings consistent with frank meningitis; often
eralized seizures, symptoms of increased intracranial pressure, and focal the causative organism is isolated on CSF culture. Blood cultures may
neurologic signs (eg, hemiparesis). Aphasia is common if the dominant be positive, especially in patients with a rapidly progressive course.
cerebral hemisphere is involved. Chest radiographs may show evidence of septic pulmonary emboli after
The findings in dural venous sinus thrombosis also depend on propagation of thrombus into the inferior petrosal sinus and jugular
location. 64,74 In cavernous sinus thrombosis, the most common com- vein. Sinus radiographs may document involvement of the paranasal
plaints are periorbital swelling (73% of cases) and headache (52%). sinuses, although conventional radiographs are inferior to MRI and CT
Headache is more common if the antecedent condition is sinusitis rather in the detection of sphenoid sinusitis.
than a facial infection. Other symptoms include drowsiness, diplopia, ■
eye tearing, photophobia, and ptosis. Fever is present in more than 90% TREATMENT
of patients. Other common signs are proptosis, chemosis, periorbital Antimicrobial Therapy: Appropriate antimicrobial therapy of septic
edema, and weakness of the extraocular muscles (due to involvement intracranial thrombophlebitis depends on the antecedent clinical con-
of cranial nerves III, IV, and VI). Because the abducens nerve is the dition. The likely organisms are similar to those observed in cranial
only cranial nerve traversing the interior of the cavernous sinus, lateral subdural empyema and epidural abscess; empirical antibiotic therapy
gaze palsy may be an early neurologic finding. Papilledema or venous should be directed toward those organisms. If the antecedent condi-
64
engorgement and a change in mental status are observed in 65% and tion is paranasal sinusitis, empirical therapy should be directed toward
55% of patients, respectively. Meningismus is present in about 40% of gram-positive organisms (staphylococci and streptococci), aerobic
cases, usually secondary to retrograde spread of the thrombophlebi- gram-negative bacilli, and anaerobes. In cavernous sinus thrombosis,
tis. About 25% of patients have dilated or sluggishly reactive pupils, an antistaphylococcal agent should always be included (because of the
decreased visual acuity (frequently progressing to blindness), and dys- high incidence of S aureus isolates) in the empirical therapeutic regimen
function of cranial nerve V. As the infection spreads to the opposite cav- pending culture results. Vancomycin is recommended, pending results
ernous sinus through the intercavernous sinuses, findings are duplicated of in vitro susceptibility testing. Intravenous antimicrobial therapy is
in the opposite eye. Persons with septic cavernous sinus thrombosis may usually continued for 3 to 4 weeks, but the duration of therapy should
present with acute or chronic illness. In the acute presentation (generally be individualized depending on the clinical response.
secondary to facial infection), the time between primary infection and
cavernous sinus thrombosis is short (<1 week), and the patient presents Surgical Therapy: Surgical intervention may be required for optimal
64
in a significantly toxic state, with rapid development of the symptoms therapy. Surgical drainage of infected sinuses is necessary when anti-
and signs described above; there is also rapid progression to bilateral microbial therapy alone is ineffective. This is especially important in
eye signs. In contrast, there is a more indolent form of cavernous sinus patients with cavernous sinus thrombosis secondary to sphenoid sinus-
thrombosis, usually secondary to dental infection, otitis media, or para- itis; some investigators have recommended operative intervention for
nasal sinusitis. In these patients, the orbital manifestations are often patients who develop cavernous venous thrombosis as a complication
unimpressive, and involvement of the contralateral eye is a late and of sinusitis. Internal jugular vein ligation has been used for lateral sinus
inconsistent finding. vein thrombosis, and thrombectomy has also been used in some situa-
Patients with septic lateral sinus thrombosis complain predominantly tions, but the efficacy of these procedures is poorly defined and not part
of headache (>80% of cases); earache, vomiting, and vertigo may also of routine management. Surgical therapy may also be required for other
occur because otitis media is a common predisposing condition. 64,74 infections (eg, dental abscess).
Fever and abnormal ear findings are observed in most patients (79% Adjunctive Therapy: The use of anticoagulants (ie, unfractionated hepa-
and 98%, respectively), and there may be seventh nerve palsy, facial rin) is recommended in patients with aseptic cerebral sinus thrombosis, 75,76
pain and altered facial sensation, papilledema, and mild nuchal rigidity. but is controversial in patients with septic intracranial thrombophlebitis.
Thrombosis of the superior sagittal sinus produces an abnormal mental There is literature to support their use in prevention of the spread of
status, motor deficits, nuchal rigidity, and papilledema. Seizures occur in thrombus from the cavernous sinus to other dural venous sinuses and
more than 50% of these patients. Patients with sinusitis as a predisposing cerebral veins. 64,74 Recent evidence has indicated that anticoagulation
condition tend to have a subacute onset of symptoms. Involvement of (in combination with antibiotics) decreases mortality rate and is most
the inferior petrosal sinus may produce ipsilateral facial pain and lateral beneficial early in the treatment of cavernous sinus thrombosis to reduce
rectus muscle weakness (Gradenigo syndrome). the morbidity rate among survivors. However, the hazards of intracranial
■ DIAGNOSIS hemorrhage (bleeding from sites of cortical venous infarction or from

The noninvasive diagnostic procedure of choice for suppurative intra- sites on the intracavernous walls of the carotid artery) must be recog-
nized. In the absence of specific contraindications, anticoagulation is
cranial thrombophlebitis is MRI. This technique visualizes blood most likely to be useful early in the course of cavernous sinus thrombosis.
64
vessels and differentiates between thrombus and normally flowing
blood. It can also demonstrate the evolution and resolution of the entire
venoocclusive process. CT, with and without use of intravenous contrast
material, also permits diagnosis of venous sinus thrombosis, although it KEY REFERENCES
is considerably less sensitive and reliable than MRI. CT usually visualizes • Brouwer MC, McIntyre P, de Gans J, et al. Corticosteroids
unilateral or bilateral multiple irregular filling defects in the enhancing for acute bacterial meningitis. Cochrane Database Syst Rev.
cavernous sinus, with or without orbital inflammatory change. An addi- 2010;9:CD004405.
tional benefit of MRI and CT is the ability to fully evaluate the paranasal
sinuses and to provide information concerning subdural and epidural • Brouwer MC, Thwaites GE, Tunkel AR, van de Beek D. Dilemmas
infection, cerebral infarction, cerebritis, hemorrhage, and cerebral in the diagnosis of acute community-acquired bacterial meningitis.
edema. Magnetic resonance angiography and venography can directly Lancet. 2012;380:1684-1692.
visualize the cerebral vasculature, differentiating thrombus from normal • Dariouiche RO. Spinal epidural abscess. N Engl J Med.
blood flow. 2006;355:2012-2020.
Other laboratory studies are usually nonspecific. 64,74 Lumbar puncture • Kim KS. Acute bacterial meningitis in infants and children. Lancet
demonstrates a mild pleocytosis (mononuclear, neutrophilic, or mixed) Infect Dis. 2010;10:32-42.
and an elevated protein concentration (consistent with a parameningeal

section05_c61-73.indd 664 1/23/2015 12:48:42 PM