Thrombosis of the sinuses of the dura mater

Thrombosis of the sinuses of the solid meninges is a complication, being in the clinical course and its outcomes an independent (nosologicized) disease, in fact, is a secondary process, arising as a complication of the local purulent-inflammatory process or general septicopyemia.

Pathogenesis

An infectious agent from a nearby foci or purulent embolus spreads through the veins, most often through veins-emissaries, if it is, for example, purulent sinusitis, otitis or furuncle of the nose, settles on the sinus wall and gives rise to thrombosis. The growing thrombus becomes infected, melts and gives a multitude of emboli that spread in the sinus along the blood stream and form new thrombi. As a result, there is a blockage of the sinus, leading to venous congestion, edema of the brain, internal and external edema of the brain and coma. With primary purulent diseases of the orbit, paranasal sinuses, carbuncle face infection is most often affected cavernous sinus. With furuncles and carbuncles of the scalp, with a face, osteomyelitis of the bones of the cranial vault, the infection penetrates into the sagittal sinus. With purulent otitis, as already noted above, thrombosis of sigmoid, stony and transverse sinuses, as well as thrombosis of the bulb of the jugular vein and thrombophlebitis of the vein itself can develop. Often, thrombus formation is not limited to only one sinus, but extends to other adjacent sinuses, and not only in the course of blood flow, but also in the opposite direction. In a particularly virulent infection, thrombosis can spread to the veins that enter the sinus and the infection can pass to the soft meninges. With infectious thrombosis of the sinus, the lumen of the latter is closed by a clot of blood or fibrin, in which there are purulent foci and pathogenic microorganisms. Purulent melting of the thrombus, as already mentioned, leads to septicopyemia and piemia with the proliferation of purulent emboli in the venous system of the small circulation and the emergence of many abscesses of the lung. Another clinical variant of the complication of thrombosis of the cerebral venous sinus is sepsis, and its complications can be septic endocarditis, nephritis, secondary thrombus formation in the venous plexuses of the abdominal cavity and pelvis.

Symptoms

The clinical picture of septic thrombosis of the cerebral sinus is characterized by septic fever, tremendous chills, profuse sweat, severe headache, vomiting, drowsiness or psychomotor agitation, delirium, epileptiform seizures, co-morbid, comatose, condition. Meningeal symptoms are of different severity and depend on proximity to the inflamed sinus of the meninges. Their appearance sharply exacerbates the clinical picture and the prognosis of the disease.

On the fundus there are stagnant phenomena in the form of veins, edema of the optic discs, more on the side of the affected sinus. Spinal-cerebral fluid is transparent or xanthochromic, sometimes with an admixture of blood, moderate pleocytosis. Liquor pressure is increased. Complication of thrombosis with meningitis causes changes in the cerebrospinal fluid, characteristic of purulent meningitis.

Thrombosis of the cavernous sinus

Thrombosis of the cavernous sinus refers to the most frequent variants of venous lesions of the brain. Usually it is a consequence of a septic condition, complicating purulent processes in the face, orbit, paranasal sinuses, less often the ear.

Against the background of sharply expressed general symptoms of sepsis, there are distinct signs of a violation of the outflow of blood through the cavernous sinus: edema of periorbital tissues, increasing exophthalmos, chemosis, edema of the eyelids, congestion on the fundus and signs of atrophy of the optic nerves. Most patients develop external ophthalmoplegia due to defeat III (n. Oculomotorius), IV (n. Trochlearis) and VI (n. Abduccns) pairs of cranial nerves. In addition, there are ptosis, pupillary disorders, corneal opacity. In essence, these phenomena are pathognomonic for thrombosis of the cavernous sinus. The defeat of the upper branch V of a pair of cranial nerves (n. Trigeminus), passing in the immediate vicinity of the cavernous sinus, causes the appearance of pain in the eyeball and forehead, a sensitivity disorder in the zone of the nascent supraorbital nerve.

Thrombosis of the cavernous sinus can be bilateral, and then the disease proceeds particularly hard. In this case, conditions are created for the destruction of the entire cavernous sinus and the spread of the process of thrombus formation into both stony sinuses and further towards the occipital sinuses. There are clinical cases of subacute flow of thrombosis of the cavernous sinus and cases of primary aseptic thrombosis, for example, in hypertension and atherosclerosis.

Diagnosis is established on the basis of a general severe septic condition, cerebral and typical eye symptoms.

Differentiate from the thrombosis of other sinuses, primary orbital diseases, hemorrhagic stroke, encephalitis of infectious etiology.

Thrombosis of the superior longitudinal sine

The clinical picture depends on the etiology, the general septic state, the rate of thrombus development, its localization within the sinus, and also the extent of involvement of the veins into the inflammatory process.

Especially severe is septic thrombosis. In thrombosis of the upper longitudinal sinus, overflow, stagnation and tortuosity of the veins of the root of the nose, eyelids, frontal, temporal "parietal areas" (a symptom of the Medusa head, and edema of the indicated areas.) Occurrence of venous congestion and increased pressure in the veins of the nasal cavity causes frequent nasal bleeding. Other symptoms should be noted soreness with percussion of the parasagittal surface of the skull.The neurologic syndrome in thrombosis of the upper longitudinal sinus consists of the symptoms of intracranial gynarthension, likely impacts of seizures, often starting with a groan. Sometimes it develops lower paraplegia with incontinence or tetraplegia.

Diagnosis with thrombosis of the superior longitudinal sinus is more difficult than with thrombosis of the cavernous or sigmoid sinus, since the observed symptoms are not so typical and often simulate many other CNS diseases. A reliable sign of thrombosis of the upper longitudinal sinus are external signs of stagnation of the superficial veins of the scalp, eyelids, the back of the nose, swelling of the venous plexuses of the nasal concha and stagnant nasal bleeding, increased relief of the cervical veins observed against the background of the septic state. Valuable information with all forms of thromboembolism of cerebral sinuses gives dopplerography of the cerebral vessels, indicating the sharp signs of disturbance of cerebral hemodynamics and venous stasis.

Differential diagnostics

Differential diagnosis is carried out in relation to the same pathological states of the brain as in infectious thrombosis of other sinuses. From thrombosis of the superior longitudinal sinus, one should distinguish the so-called muranic thromboses of the brain sinuses, which usually develop in elderly persons against the background of senile decay with concomitant general chronic or acute infections, as well as thrombosis of cerebral sinuses in infants with various diseases leading to exhaustion (dysentery , dyspepsia, chronic infections, congenital heart defects, etc.). In the case of a manic thrombosis, the cavernous sinus, rarely the straight line, and rarely other sines, are most often affected.

The clinical picture develops subacute: there are headaches, nausea, vomiting, insomnia, loss of appetite, apathy. On the fundus there are congestive discs of the optic nerves. Of the neurological symptoms, the most common are general or Jacksonian seizures, lower paraparesis with urinary incontinence or paresis of one leg, or hemiparesis. Intravital diagnosis is very difficult. Dopplerography indicates venous congestion in the brain. Diagnosis is helped by the presence of a chronic infection, the cachexic appearance of the patient, his age.

[1], [2], [3], [4], [5], [6], [7]

Treatment

Treatment of rhinogenic thrombosis of cerebral sinuses provides, as an urgent measure, the elimination of the primary focus of infection followed by its intensive sanation. In the case of rhinogenic thrombosis of the sinuses of the dura mater, a wide opening of the causal paranasal sinus is often used, often a hemisinusotomy or pansinusotomy with a radical removal of pathologically altered tissues, systematic postoperative care for the postoperative cavities against the background of the above antibiotic therapy. Assign also anticoagulants, diuretics, immunoprotectors, vitamins, high-grade protein nutrition.

Forecast

The prognosis for rhinogenic thrombosis of the veins and sinuses of the brain is determined by the same factors as the rhinogenic brain abscesses, but with the rhinogenic inflammatory diseases of the venous system of the brain, the prognosis is more serious and often pessimistic, especially with deep vein thrombosis, cavernous sinuses and advanced sepsis. Early intravenous, intraluminal and intracarotid antineopathic therapy with powerful support of thrombolytic, specific antimicrobial and immunological treatment facilitates prognosis.

[8], [9], [10], [11], [12], [13]