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INTRACRANIAL SEPTIC THROMBOPHLEBITIS
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The dural sinuses drain blood from all of the brain into the jugular veins The largest and most important of these, and the ones usually involved by infection, are the lateral (transverse), cavernous, petrous, and, less frequently, the longitudinal (sagittal) sinuses A complex system of lesser sinuses and cerebral veins connects these large sinuses to one another as well as to the diploic and meningeal veins and veins of the face and scalp The basilar venous sinuses are contiguous to several of the paranasal sinuses and mastoid cells Usually there is evidence that thrombophlebitis of the large dural sinuses has extended from a manifest infection of the middle ear and mastoid cells, the paranasal sinuses, or skin around the upper lip, nose, and eyes Other forms of intracranial suppuration frequently complicate these cases, including meningitis, epidural abscess, subdural empyema, and brain abscess Occasionally, infection may be introduced by direct trauma to large veins or dural sinuses A variety of organisms, including all the ones that ordinarily inhabit the paranasal sinuses and skin of the nose and face, may give rise to intracranial thrombophlebitis Streptococci and staphylococci are the ones most often incriminated With the exception of fever and poorer outcome, the syndromes associated with septic phlebitis are similar to those produced by bland thrombosis of the veins, as discussed in Chap 34, on cerebrovascular diseases Septic Lateral (Transverse) Sinus Thrombophlebitis In lateral sinus thrombophlebitis which usually follows chronic infection of the middle ear, mastoid, or petrous bone earache and mastoid tenderness are succeeded, after a period of a few days to weeks, by generalized headache and, in some instances, papilledema If the thrombophlebitis remains con ned to the transverse sinus, there are no other neurologic signs Spread to the jugular bulb may give rise to the syndrome of the jugular foramen (see Table 47-1) and involvement of the torcula, leading to increased intracranial pressure One lateral sinus, usually the right, is larger than the other, which may account for greatly elevated pressure when it is occluded Contiguous involvement of the superior sagittal sinus causes seizures and focal cerebral signs (see below) Fever, as in all forms of septic intracranial thrombophlebitis, tends to be present but intermittent, and other signs of the septic state may be prominent Infected emboli may be released into the bloodstream, causing petechiae in the skin and mucous membranes and pulmonary sepsis The CSF is usually normal but may show a small number of cells and a modest elevation of protein content Imaging by MR and CT has supplanted cerebral venography, arteriography, and the various older tests involving compression of the jugular veins in the diagnosis of venous sinus thrombosis MRI sequences that are appropriate to the slow blood ow in the cerebral venous system must be selected and imaging planes carefully chosen to pass through the venous sinuses CT and MRI at the same time are able to detect abscess and hydrocephalus Prolonged administration of high doses of antibiotics is the mainstay of treatment Anticoagulation, shown to be bene cial in
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MAJOR CATEGORIES OF NEUROLOGIC DISEASE
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scan performed early in the illness without contrast infusion usually shows the high-density clot within cortical veins as well, but only if carefully studied by altering the viewing window at the machine s console Treatment consists of large doses of antibiotics and temporization until the thrombus recanalizes Although not of proven bene t (as it is in bland cerebral vein thrombosis), we have used heparin in these circumstances unless there are very large biparietal hemorrhagic infarctions Because of the high incidence of occlusion of cortical veins that drain into the sagittal sinus and the highly epileptogenic nature of the attendant venous infarction, we have also administered anticonvulsants prophylactically, but there is no adequate clinical study to guide the clinician in this regard Recovery from paralysis may be complete, or the patient may be left with seizures and varying degrees of spasticity in the lower limbs It should be reiterated that all types of thrombophlebitis, especially those related to infections of the ear and paranasal sinuses, may be simultaneously associated with other forms of intracranial purulent infection, namely bacterial meningitis, subdural empyema, or brain abscess Therapy in these complicated forms of infection must be individualized As a rule, the best plan is to institute antibiotic treatment of the intracranial disease and to decide, after it has been brought under control, whether surgery on the offending ear or sinus is necessary To operate on the primary focus before medical treatment has taken hold is to court disaster In cases complicated by bacterial meningitis, treatment of the latter usually takes precedence over the surgical treatment of complications, such as brain abscess and subdural empyema Aseptic thrombosis of intracranial venous sinuses and cerebral veins is discussed in Chap 34 (page 735), on cerebrovascular disease; aspects related to intracranial pressure are discussed in Chap 30, on CSF circulation
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