A 66-year-old female with a history of sinusitis presented with persistent diplopia and worsening eyelid swelling. Examination revealed bilateral vision loss, cranial nerve palsies, left-sided chemosis, proptosis, and edema. Initial imaging showed sphenoid sinus opacification, bilateral ethmoid disease, lack of filling of bilateral cavernous sinuses, and partial thrombosis of the left superior ophthalmic vein. The sinus findings were evaluated with endoscopic sinus surgery, which was unremarkable. Subsequent orbital imaging suggested the lesions were in keeping with tumor thrombus as opposed to bland thrombus. CT scans revealed a large mass in the right axilla, which was biopsied and confirmed the diagnosis of diffuse large B-cell lymphoma (DLBCL). The patient was treated with anticoagulation, steroids, and chemotherapy resulting in marked improvement. Our report highlights a rare case of tumor thrombus from DLBCL causing bilateral cavernous sinus thrombosis and, to the best of our knowledge, the first documented case of superior ophthalmic vein thrombosis from tumor thrombus.

UNASSIGNED: Postoperative visual loss (POVL) is a relatively rare but devastating complication. We reported a case of POVL after spine surgery caused by ischemia of retina and optic nerve, and firstly introduced the possibility of cavernous sinus thrombosis in POVL development.
METHODS: A 67-year-old woman diagnosed with \"lumbar spinal stenosis\" was admitted to undergo posterior lumbar spinal canal decompression surgery because of the persistent lumbago and numbness. The operation was performed in the prone position under general anesthesia uneventfully. On the second day, the visual acuity of her right eye suddenly decreased to no light perception. The ophthalmic examination indicated edematous eyelid, chemosis, ptosis, ophthalmoplegia, relative afferent pupillary defect and higher orbital pressure in her affected eye, and funduscopic examination revealed pale optic disc, diffuse retinal welling and attenuated arteries. Cerebral magnetic resonance angiography implied the stenosis of cavernous sinus segment of right internal carotid artery. Aseptic cavernous sinus thrombosis and the secondary combined occlusion of central retinal and optic nerve vessels were suspected. Therefore, anticoagulation, vasodilation, oxygen and anti-inflammation treatment were timely administrated. One month after the treatment, swelling eyelid and ocular motion had markedly improved. However, there was no remarkable improvement in the patient\'s visual acuity.
UNASSIGNED: Postoperative visual loss (POVL) after spine surgery is regarded as a serious complication with irreversible vision damage. It was alarming that cavernous sinus thrombosis might be a possible cause of POVL. High-volume fluid replacement, unstable hemodynamic parameters, prone position and prolonged surgical duration might bring about microvascular diseases and hypercoagulable state, contributing to the occurrence of POVL.
CONCLUSIONS: Our study firstly implied the possibility of cavernous sinus thrombosis in the POVL development. Detailed assessment, fluids management, hemodynamic stabilizing and duration optimization were proposed for POVL prevention.

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BACKGROUND: Intracavernous infectious aneurysm (ICIA), represents a rare entity that is always described in the form of case reports in the literature. The coexistence of ICIA and cavernous sinus thrombosis (CST) is extremely rare and poorly understood.
METHODS: A 53-year-old female patient presented to our hospital with headache, nausea and fatigue for 3 weeks. She complained of blurry vision and drooping eyelids before admission. Neurological examination revealed bilateral decreased visual acuity, limitation of extraocular movements and decreased sensation of forehead. Brain magnetic resonance imaging (MRI) showed mixed signal intensities in both cavernous sinuses and expansion of right superior ophthalmic vein, suggesting the formation of CST. One month later, computed tomography angiography (CTA) confirmed a large aneurysm was attached to the left intracavernous carotid artery (ICCA).
UNASSIGNED: This patient was diagnosed with ICIA and CST.
METHODS: She was administered with intravenous meropenem and vancomycin and subcutaneous injection of low molecular heparin for 4 weeks.
RESULTS: One month later, her extraocular movement had significantly improved, without ptosis and conjunctival congestion. At 1-year follow-up, her ophthalmoplegia fully recovered. Fortunately, such large aneurysm did not rupture in spite of slight broadening.
CONCLUSIONS: The coexistence of ICIA and CST is extremely rare. Contiguous infection from adjacent tissues is the foremost cause of ICIA. A repeated angiographic examination is recommended under enough anti-infective treatment due to the characteristics of rapid emergence and fast growth of infectious aneurysms.

Brain and ocular infections can be the worst and fatal consequences of sinonasal infections in immunomodulated or immunocompromised patients. We report a case of a 35-year-old female who received an allogenic hematopoietic stem cell transplantation for acute myeloid leukemia, suffering from maxillo-spheno-ethmoidal rhinosinusitis which was complicated by cavernous sinus thrombosis, orbital cellulitis, optic ischemia and cerebritis.

BACKGROUND: Cavernous sinus thrombosis (CST) is a serious condition that carries with it a high rate of morbidity and mortality.
OBJECTIVE: This review highlights the pearls and pitfalls of CST, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.
CONCLUSIONS: CST is a potentially deadly thrombophlebitic disease involving the cavernous sinuses. The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST, though other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications. Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies. The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes). Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy. Other CNs that may be affected include III, IV, and V. The disease may also affect the pulmonary and central nervous systems. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases. Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity. Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation.
CONCLUSIONS: An understanding of CST can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Ophthalmic vein thrombosis is a severe clinical entity with proptosis, eyelid swelling, orbital pain and reduction of visual acuity; its incidence is rare with 3-4 cases /million /year. Clinical manifestations result from venous congestion caused by septic (orbital cellulitis) or aseptic aetiologies (coagulopathies, trauma) and in some cases it could be associated with cavernous sinus thrombosis. In this paper, we describe a case report unique in the literature, of bilateral cavernous sinus and ophthalmic veins thrombosis due to both septic and aseptic causes characterized by unilateral sphenoid sinusitis sustained by Trueperella pyogenes infection. Trueperella pyogenes is an opportunistic animal pathogen, and its infections occur in both domestic and wild animals worldwide but are rare in humans; this is the first instance of human infection in the head and neck with an unknown hypercoagulable state.

Streptococcus constellatus pharyngis is a gram-positive commensal bacterium commonly found in the oropharynx, gastrointestinal and urogenital tracts. It might be an aggressive opportunistic pathogen causing invasive pyogenic infections in sterile areas, mostly as peritonsillar and orofacial abscesses. We report the case of a 6-year-old girl, who presented multiple head and neck abscesses and bilateral cavernous sinus thrombosis secondary to Streptococcus constellatus pharyngis. Cavernous sinus thrombosis, consequent to this microorganism, has not been reported to date in the literature. Due to the invasive features of this pathogen, a long-term antibiotherapy (up to 9 months) is required. Additionally, a surgical drainage is indicated in case of head and neck, or brain abscesses, larger than 20 or 25 mm respectively. Anticoagulation should be considered in case of venous thrombosis. The interest of this case is not only based on the rarity and severity of the disease, but also on the success of medical and surgical therapy (including long- term antibiotics, anticoagulation and two surgical procedures). This experience may serve as a guide to treat future cases.
UNASSIGNED: The online version contains supplementary material available at 10.1007/s12070-024-04511-3.

Cavernous sinus thrombosis is a potentially lethal subset of cerebral venous sinus thrombosis that may occur as a result of septic and aseptic etiologies. The overall incidence is estimated to be between 0.2 and 1.6 per 100,000 persons; and treatments include antibiotics, anticoagulation, corticosteroids, and surgery. Recent morbidity and mortality estimates are approximately 15% and 11%, respectively. Rapid identification and treatment are essential and may reduce the risk of poor outcome or death.

Background: Various diseases involving the cavernous sinus can cause a condition called cavernous sinus syndrome (CSS), which is characterized by ophthalmoplegia or sensory deficits over the face resulting from the compression effect of internal structure. While tumor compression is the most reported cause of CSS, statistical data on CSS caused by infections are limited. Its risk factors, treatment methods, and clinical outcomes are not well-documented. Methods: In this retrospective study, we reviewed the data of patients admitted to a tertiary medical center from 2015 to 2022 with a diagnosis of acute and chronic sinusitis and at least one diagnostic code for CSS symptoms. We manually reviewed whether patients were involved in two or more of the following cranial nerves (CN): CN III, CN IV, CN V, or CN VI, or at least one of these nerves with a neuroimaging-confirmed lesion in the cavernous sinus. Results: Nine patients were diagnosed with rhinosinusitis-related CSS. The most common comorbidity was type 2 diabetes, and the most common clinical manifestations were diplopia and blurred vision. The sphenoid sinus was the most affected sinus. One patient expired due to a severe brain abscess infection without surgery. The remaining patients underwent functional endoscopic sinus surgery, and 50% of the pathology reports indicated fungal infections. Staphylococcus spp. was the most cultured bacteria, and Amoxycillin/Clavulanate was the most used antibiotic. Only four patients had total recovery during the follow-up one year later. Conclusions: CSS is a rare but serious complication of rhinosinusitis. Patients with diabetes and the elderly may be at a higher risk for this complication. Even after treatment, some patients may still have neurological symptoms.