Use of ventriculostomy in the treatment of septic cavernous sinus thrombosis (SCST)

Abstract

We present a novel treatment with the use of intraventricular antibiotics delivered through a ventriculostomy in a patient who developed septic cavernous sinus thrombosis after sinus surgery. A 65-year-old woman presented with acute on chronic sinusitis. The patient underwent a diagnostic left maxillary antrostomy, ethmoidectomy, sphenoidotomy and sinusotomy. Postoperatively, the patient experienced altered mental status with episodic fever despite treatment with broad-spectrum antimicrobial therapy. MRI of the brain showed extensive meningeal enhancement with the involvement of the right trigeminal and abducens nerve along with thick enhancement along the right pons and midbrain. MR arteriogram revealed a large filling defect within the cavernous sinus. Intraventricular gentamicin was administered via external ventricular drain (ie, ventriculostomy) every 24 hours for 14 days with continued treatment of intravenous ceftriaxone and metronidazole. The patient improved with complete resolution of her cavernous sinus meningitis on repeat brain imaging at 6 months posthospitalisation.

Keywords: drug therapy related to surgery; ear, nose and throat/otolaryngology; infection (neurology); meningitis; neurosurgery.

Figure 1

Cavernous sinus meningitis (below) with associated cavernous sinus thrombosis (not shown). T1-weighted contrast enhanced MRI of the brain revealed extensive meningeal enhancement (arrows) adjacent to the anterolateral border of the midbrain (A), pontine tegmentum (B–E), with circumferential involvement around the cavernous and supraclinoid carotid artery. There is involvement along the right trigeminal and abducens nerves. Diffusion weighted imaging demonstrated areas of restricted diffusion (F) suggestive of abscess formation centred in the region of the right ambient and interpeduncular cisterns.

Figure 2

Follow-up imaging of cavernous sinus meningitis after treatment with intraventricular antibiotic therapy. T1-weighted contrast enhanced MRI of the brain (A–E) revealed resolution of meningeal enhancement and associated intracranial abscess. Diffusion weighted imaging demonstrates resolution of the restricted diffusion with subtle low signal changes within the pontine tegmentum suggestive of encephalomalacia (F, arrow).