XL Cerebral Venous Thrombosis

Abstract

In the course of nasal sinus and middle ear infections, supervening signs of focal cerebral involvement are usually indicative of brain abscess.53, 25,93,5 There are, however, certain instances when brain abscess is strongly suspected because of signs of focal cerebral involvement but is not found on surgical exploration or demonstrated by contrast roentgenography, and, the clinical course reverses toward recovery.Adson! believed that, in this type of case, the infection extended into the brain but resolved without suppuration. He called the condition pseudo-brain abscess. Others have referred to it as acute non-suppurative encephalitis, or local non-suppurative meningitis.": 87Our interest in this problem was aroused by three patients (Cases Nos. 3,4 and 5) who presented themselves within a single year. They were remarkably alike in that they developed, in the course of paranasal sinus infection, focal seizures, hemiparesis and signs of meningeal irritation. They were strongly suspected of having abscess but appropriate investigation ruled otherwise, and, they recovered without the necessity of intracranial exploration. We can only speculate on the cause of the neurological signs.

Cortical Thrombophlebitis and Otogenous Intracranial Hypertension

“…1 It has also been reported in cachectic conditions and blood dyscrasias and it may arise in pregnancy or the puerperium. General reviews by Kendall (1948), Garcin and Pestel (1949), and Stuart et al (1951) illustrate the various conditions in which cortical thrombophlebitis may develop.…”

“…This is emphasized by the fact that focal cerebral signs were present in 43 patients with (otogenic) temporal lobe abscess and three with (otogenic) subdural abscess who were admitted over the same period as the above cases. Cortical thrombophlebitis may precede or co-exist with brain abscess, but the lesions are not commonly demonstrated together and such an association was present in less than four per cent, of brain abscesses reviewed by Stuart et al (1951). Likewise, cortical thrombophlebitis may be associated with meningitis, and it is only after the presence of intracranial suppuration has been excluded in a patient with otitis media and focal cerebral signs that the syndrome of otogenic cortical thrombophlebitis may be diagnosed.…”

On the Management of Oto-Rhinogenic Intracranial Infections

“…Possibly, however, these procedures may show abnormal features in some cases of encephalitis-especially if the latter be more or less localized (e.g. Case 12, with haemorrhagic cerebral softening, of Stuart, O'Brien andMcNally, 1951, andCrawford, 1954); further knowledge is required here. A patient may be so desperately ill that it may be considered wiser to explore for a brain abscess straight away.…”

“…The diagnosis in this case would appear to have been otogenic non-purulent encephalitis. The post-operative course ^night^ have been less stormy had the brain been merely decompressed and not also explored, but a diagnosis of brain abscess, probably in the temporal lobe, appeared so likely that it was not considered necessary to carry out electro-or angioencephalography--which might, anyway, have been misleading; Stuart, O'Brien and McNally (1951) report a case showing classical signs of a left otogenic temporal lobe abscess in which ventriculography indicated a left temporo-parietal space-occupying lesion and surgical exploration revealed haemorrhagic softening in the temporal lobe. Their patient was older, and X-rays showed a shift of the calcined pineal gland to the right.…”

“…However, such cases require prolonged observation and perhaps electro-or pneumo-encephalography to ensure that an abscess has not been merely temporarily "subdued". A differential diagnosis is cerebral venous thrombosis complicating aural or sinus sepsis; the treatment is similar (Stuart et al, 1951); differentiation appears impossible without visualization of the pathology, but perhaps further experience with angiography may help; the value of anticoagulants in cerebral venous thrombosis is doubtful--it may be dangerous. The case reported in the following summarized history raised such considerations.…”