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i89

Case

Iatrogenic Mark

Adams,1

Air in the Cavernous Douglas

J. Quint,1

0. Petter

and

Report

A 4-month-old respiratory

girl with increasing

tract

infection,

and

irritability,

symptoms

of an upper

of 39.4#{176}C was admitted

a temperature

to the hospital for evaluation of possible sepsis and meningitis. Physical and neurologic examinations were unremarkable. Lateral radiographs

of the

were interpreted showed

neck,

made

to exclude

as suggestive

no evidence

a retropharyngeal

of a retropharyngeal

of a retropharyngeal

mass.

abscess,

mass. CT per-

However,

gas

was

detected bilaterally in the cavernous sinuses on the contrast-enhanced scan (Fig. 1). Although this gas was initially considered consistent with infection, review of the unenhanced CT scan, which had been obtained minutes before the enhanced scan, showed no gas in the cavernous sinuses. As the contrast material had been administered through a scalp vein, the gas was thought to have been unintentionally

introduced

during

the

IV

injection

of

the

The

ultimate

diagnosis attributable

in this

child

to

air

the

was

Kawasaki

disease.

No

in the

cavernous

sinuses

oc-

curred.

Discussion

Gas in the cavernous with infection, trauma,

sinus has been reported in association and surgery [1 -3]. This gas has been

Received November 1 8, 1991 ; accepted after revision December I Department of Radiology, Box 30, Neuroradiology (B1 D530H), Address reprint 2 Department AJR 159:189-190,

requests to D. J. Quint. of Radiology, LMleval Hospital, July

1992 0361 -803X/92/1

Oslo,

confused with normal fat in the cavernous sinus [4]. Imaging of gas in the cavernous sinus was first reported by Curnes et al. [i] in 1 987 in a patient in whom this condition was

associated

1 6, 1991. University

Roentgen

sinus thrombosis.

In 1988,

gas found in the cavernous sinus in our patient. She had no signs of cavernous sinus thrombosis [1 , 5], no history of trauma, and no secondary signs of trauma to the skull base. Gram stains, cultures, and viral indexes of blood, urine, and

CSF were negative

for infection.

The ultimate

source

of the

child’s The

fever was thought to be Kawasaki disease. veins of the head do not have valves, and therefore blood and its contents can tnaveh unimpeded in either direction. The veins of the scalp, forehead, and face and their

with the cavernous

sinuses

are well described

[6]. In our patient, the most likely pathway for the air embohus introduced through the catheter in the scalp vein was through the anterior superficial temporal veins to the frontal vein to the nasofrontal vein to the superior ophthalmic vein to the cavernous sinus. In another patient with contrast material injected through a scalp vein, we have seen dramatic opacification of this pathway (Fig. 2). Finally, with inappropriate (i.e., too narrow) windowing of the CT scans at the console or during photography, fat, which

of Michigan

Norway.

591 -01 89 © American

with septic cavernous

Bartynski and Wang [2] described a patient with air in the cavernous sinus after traumatic fracture of the skull base. To the best of our knowledge, air in the cavernous sinus as a complication of administration of IV contrast material has never been reported. hatnogenically introduced am is the most likely source of the

anastomoses

contrast

material. complications

Sinus

Eldevik2

Air in the cavernous sinus may be caused by trauma, surgery, or infection. We report a case that occurred in association with IV injection of contrast material through a catheter into a scalp vein.

Case

Report

Ray Society

Hospitals,

1 500

E. Medical

Center

Dr., Ann Arbor,

MI 48109-0030.

ADAMS

190

ET AL.

AJR:159,JuIy

Fig. 1.-4-month-old

girl with fever

1992

due to

Downloaded from www.ajronline.org by 117.255.249.147 on 11/08/15 from IP address 117.255.249.147. Copyright ARRS. For personal use only; all rights reserved

Kawasaki disease. contrast-enhanced CT scan of head shows gas in cavernous sinuses (arrows). Contrast material had been injected through a venous catheter in left side of scalp. Unenhanced scan obtained approximately 20

mm earlier mahitles.

Fig.

showed

2.-Neonate

no cavernous

sinus abner-

being evaluated

zures. CT scan obtained after injection trast material through a venous catheter shows opacification

tions.

It can suggest

a fracture

sinus in imphica-

of the skull base or an infection

that requires rapid and definitive management. However, if gas is seen in the cavernous sinus and no clinical explanation

1 . Curnes

associated with a disease) should be absorbed during this interval. The finding of iatrogeniCally introduced air adds to the

5.

of gas in the cavernous

phasizes the importance trast material is injected

of meticulous IV.

sinus

technique

and reem-

when con-

JT, Creasy

JL, Whaley

AL, Scatliff

JH. Air in the cavernous

sinus:

a new sign of septic cavernous sinus thrombosis. AJNR 1987;8: 176-1 77 2. Bartynski WS, Wang AM. Cavemous sinus air in a patient with basilar

3.

diagnosis

air may sinus.

REFERENCES

is apparent, the study should be repeated within several days before invasive therapy is initiated. This should be done to confirm the finding, as accidentally injected air (i.e., gas not

differential

of conin scalp

of left superior ophthalmic

vein (arrows), confirming a route that travel from a scalp vein to the cavernous

can normally be seen in the region of the cavernous some patients [7], can be mistaken for air [4]. Gas within the cavernous sinus can have serious

for sei-

4.

6. 7.

skull fracture: CT identification. J Comput Assist Tomogr 1988;12: 141 -142 Frost EAM. Some inquiries in neuroanesthesia and neurological supportive care. J Neurosurg 1984;60:673-686 Navarrete ML, Galindo J, Pellicer M, Barcelona S. Cavemous sinus air bubble. Ear Nose Throat J 1990;69:771-772 Hirsch WL, Roppolo HMN, Hayman LA, Hinck VC. Sella and parasellar regions: pathology. In: Latchaw RE, ed. MR and CT imaging of the head, neck, and spine, 2nd ed. St. Louis: Mosby, 1991:717 Gray H. Gray’s anatomy, 29th ed. Philadelphia: Lea and Febiger, 1973: 683-695 Stncof DD, Gabrielsen TO, Latack JT, Gebarski 55, Chandler WF. CT demonstration of cavernous sinus fat. AJNR 1989;10: 1199-1201