Thrombosis of the dura sinuses

Thrombosis of the sinuses of the dura mater is a complication, being an independent (nosologically formed) disease in terms of its clinical course and outcomes, in essence, it is a secondary process that occurs as a complication of a local purulent-inflammatory process or general septicopyemia.

Pathogenesis

An infectious agent from a nearby focus or a purulent embolus spreads through the veins, most often through the emissary veins, if we are talking about, for example, purulent sinusitis, otitis or a furuncle of the nose, settles on the sinus wall and gives rise to thrombus formation. The growing thrombus becomes infected, melts and produces many emboli, which spread in the sinus along the blood flow and form new thrombi. As a result, there is a sinus blockage, leading to venous congestion, cerebral edema, internal and external hydrocephalus and coma. In primary purulent diseases of the orbit, paranasal sinuses, carbuncle of the face, the cavernous sinus is most often affected by infection. In furuncles and carbuncles of the scalp, erysipelas, osteomyelitis of the bones of the cranial vault, the infection penetrates the sagittal sinus. In purulent otitis, as already noted above, thrombosis of the sigmoid, petrosal 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 just one sinus, but spreads to other adjacent sinuses, and not only in the direction of blood flow, but also in the opposite direction. In a particularly virulent infection, thrombosis can spread to the veins flowing into the sinus, and the infection can pass to the pia mater. In infectious thrombosis of the sinus, the lumen of the latter is closed by a blood or fibrin clot, which contains purulent foci and pathogenic microorganisms. Purulent melting of the thrombus, as already mentioned, leads to septicopyemia and pyemia with the spread of purulent emboli through the venous system of the pulmonary circulation and the occurrence of multiple lung abscesses. Another clinical variant of complication of cerebral venous sinus thrombosis 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, shaking chills, profuse sweating, severe headache, vomiting, drowsiness or psychomotor agitation, delirium, epileptiform seizures, soporous, turning into a comatose state. Meningeal symptoms can be of varying severity and depend on the proximity of the meninges to the inflamed sinus. Their appearance sharply worsens the clinical picture and prognosis of the disease.

The fundus reveals congestion in the form of varicose veins, edema of the optic discs, more on the side of the affected sinus. The cerebrospinal fluid is transparent or xanthochromic, sometimes with an admixture of blood, moderate pleocytosis. The cerebrospinal fluid pressure is increased. Complication of thrombosis by meningitis causes changes in the cerebrospinal fluid characteristic of purulent meningitis.

Cavernous sinus thrombosis

Thrombosis of the cavernous sinus is one of the most common types of venous brain lesions. It is usually a consequence of a septic condition that complicates purulent processes in the face, orbit, paranasal sinuses, and, less commonly, the ear.

Against the background of pronounced general symptoms of sepsis, there are clear signs of impaired blood outflow through the cavernous sinus: edema of the periorbital tissues, increasing exophthalmos, chemosis, eyelid edema, congestion in the fundus and signs of optic nerve atrophy. Most patients develop external ophthalmoplegia due to damage to the III (n. oculomotorius), IV (n. trochlearis) and VI (n. abduccns) pairs of cranial nerves. In addition, ptosis, pupillary disorders, and corneal opacity are observed. In essence, these phenomena are pathognomonic for cavernous sinus thrombosis. Damage to the upper branch of the V pair of cranial nerves (n. trigeminus), passing in close proximity to the cavernous sinus, causes pain in the eyeball and forehead, and sensitivity disorders in the area affected by the supraorbital nerve.

Cavernous sinus thrombosis may be bilateral, and then the disease is particularly severe. In this case, conditions are created for the entire cavernous sinus to be affected and for the thrombus formation process to spread to both petrosal sinuses and further towards the occipital sinuses. There are clinical cases of subacute cavernous sinus thrombosis and cases of primary aseptic thrombosis, for example, in hypertension and atherosclerosis.

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

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

Thrombosis of the superior longitudinal sinus

The clinical picture depends on the etiology, the general septic condition, the rate of thrombus development, its localization within the sinus, as well as the degree of involvement of the veins flowing into it in the inflammatory process.

Septic thrombosis is especially severe. With thrombosis of the superior longitudinal sinus, there is overflow, congestion and tortuosity of the veins of the root of the nose, eyelids, frontal, temporal "parietal areas (symptom of the head of Medusa), as well as edema of the above areas. The occurrence of venous congestion and increased pressure in the veins of the nasal cavity cause frequent nosebleeds. Other symptoms include pain on percussion of the parasagittal surface of the skull. Neurological syndrome in thrombosis of the superior longitudinal sinus consists of symptoms of intracranial hypertension, convulsive seizures, often beginning with a groan. Sometimes lower paraplegia with urinary incontinence or tetraplegia develops.

Diagnosis of thrombosis of the superior longitudinal sinus is more difficult than that of thrombosis of the cavernous or sigmoid sinus, since the observed symptoms are not so typical and often simulate many other diseases of the central nervous system. A reliable sign of thrombosis of the superior longitudinal sinus is external signs of congestion of the superficial veins of the scalp, eyelids, bridge of the nose, swelling of the venous plexuses of the nasal conchae and congestive nosebleeds, increased relief of the jugular veins observed against the background of a septic condition. Valuable information in all forms of thromboembolism of the cerebral sinuses is provided by Dopplerography of the cerebral vessels, indicating sharp signs of impaired cerebral hemodynamics and venous congestion.

Differential diagnostics

Differential diagnostics are carried out in relation to the same pathological conditions of the brain as in infectious thrombosis of other sinuses. From thrombosis of the superior longitudinal sinus, one should distinguish the so-called marantic thromboses of the cerebral sinuses, which usually develop in elderly people against the background of senile decrepitude with concomitant general chronic or acute infections, as well as from thrombosis of the cerebral sinuses in infants with various diseases leading to exhaustion (dysentery, dyspepsia, chronic infections, congenital heart defects, etc.). In marantic thrombosis, the cavernous sinus is most often affected, less often the straight sinus and very rarely other sinuses.

The clinical picture develops subacutely: headaches, nausea, vomiting, insomnia, loss of appetite, apathy appear. In the fundus - congestion of the optic nerves. Of the neurological symptoms, the most characteristic are general or Jacksonian seizures, lower paraparesis with urinary incontinence or paresis of one leg, or hemiparesis. Lifetime diagnosis is very difficult. Dopplerography indicates venous congestion in the brain. The presence of chronic infection, the cachectic appearance of the patient, his age help in diagnosis.

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Treatment

Treatment of rhinogenic thrombosis of the cerebral sinuses involves, as an emergency measure, the elimination of the primary source of infection with its subsequent intensive sanitation. In rhinogenic thrombosis of the sinuses of the dura mater, a wide opening of the causative paranasal sinus is used, often hemisinusotomy or pansinusotomy with radical removal of pathologically altered tissues, systematic postoperative care of the postoperative cavities against the background of the above method of antibiotic therapy. Anticoagulants, diuretics, immunoprotectors, vitamins, and complete protein nutrition are also prescribed.

Forecast

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

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