1978, British Journal of Radiology, 57,913-914
NOVEMBER
1978
Case reports Non-thrombotic occlusion of the cavernous carotid from subdurai empyema By R. W. Katzberg, M.D.* and G. Griffiths, M.B., B.C.H., D.C.H., F.R.C.R.f Department of Diagnostic Radiology, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642. {Received August, 1976 and in revisedform April, 1978)
Scattered reports of the significant angiographic findings in intracranial bacterial infection have demonstrated several types of vascular changes, many of which are non-specific. These include narrowing or spasm of the major vessels at the base of the brain, segmental arterial dilatation, peripheral arterial occlusions, aneurysmal formation due to vessel wall involvement by infection, arterio-venous shunting and a thickened vascular wall of the dura (Ferris et ah, 1968). The angiographic appearance of narrowing of a vessel may result from cellular infiltration, oedema of the wall, extrinsic compression or irritability of the vessel wall with actual vasospasm •Present address: Wilford Hall, USAF Medical Center/ SGHR Lackland AFB, Texas 78236. fPresent address: Department of Radiology, Royal Gwent Hospital, Newport, Gwent.
(Ferris and Levine, 1973). Progression of these changes to non-thrombotic occlusion has been observed in the smaller arteries of the brain. This is the first case demonstrating radiographic and pathologic documentation of non-thrombotic occlusion of the internal carotid artery secondary to intracranial infection. CASE HISTORY
A nine-month old female infant was admitted to Strong Memorial Hospital with a seven day history of upper respiratory infection, fever, and a purulent discharge from the left external auditory canal. Physical examination disclosed oedema of the left side of the head, a right central eighth nerve palsy and a right hemiparesis, which developed into decerebrate posturing. A left subdurai tap showed clear cerebrospinal fluid under no pressure. There was no growth on culture of the blood, cerebrospinal fluid or ear drainage, but gram positive micrococci were noted in the latter. An angiogram showed no internal cerebral circulation to the left hemisphere after a left common carotid injection. A
FIG. 1. (A) Anteroposterior and (B) lateral subtraction views following a right common carotid injection showing a long segment of severe narrowing of the cavernous portion of the internal carotid artery.
913
VOL.
51, No. 611 Case reports
Vascular spasm frequently observed with intracranial bacterial infection presumably is the result of irritation to the arterial wall from the surrounding inflammatory material, causing luminal narrowing (Ferris et al., 1968). Structural changes result from inflammatory involvement of the vessel wall itself with resultant intimal proliferations and inflammatory cells in all layers (Greitz, 1964). There are variable degrees of fibrosis with acute and chronic cellular infiltrates in the subarachnoid space. Progressive narrowing of the lumen leads to thrombosis with occlusion. Complete arterial occlusion without thrombosis has been reported to occur in various segments of the intracranial circulation, usually peripherally (Ferris FIG. 2. and Levine, 1973). Failure to fill the internal carotid High power photomicrograph of the left cavernous carotid artery has been described in cases of raised intraartery which shows marked luminal narrowing associated with mild intimal thickening and polymorphonuclear cells cranial pressure and termed "pseudo-occlusion" (Newton and Couch, 1960). This case is exceptional in the adventitia. in that it is the first report of non-thrombotic long segment of severe narrowing affecting mainly the occlusion of the vascular supply to an entire cerebral cavernous portion of the right internal carotid artery was hemisphere not resulting from increased intraalso demonstrated (Fig. 1). The circulation time was cranial pressure. markedly prolonged. Pathologic correlation of the left internal carotid The patient continued to deteriorate and the following day had a cardiac arrest and died. demonstrates acute inflammatory cells in the advenAt post-mortem examination a subdural empyema of the left middle cranial fossa was found with bilateral septic titia with only mild intimal thickening. The contrathrombosis of the cavernous sinuses resulting from a left lateral cavernous carotid shows changes of focal inotitis media and acute osteomyelitis of the left petrous timal thickening without inflammatory cellular inbone. Microscopy demonstrated severe stenosis of the left cavernous carotid artery without thrombosis and with poly- filtrations. This appearance is similar to that in early morphonuclear infiltration of the adventitia (Fig. 2), The atherosclerosis of the mature circulatory system. The intima was slightly thickened and the vascular lumen marked angiographic findings are disproportionate measured 66 microns. The lumen of the right cavernous carotid artery was 600 microns in diameter with focal intimal to the microscopic structural alterations and this thickening and acute and chronic peri-adventitial inflamma- may implicate spasm as a major modifying factor. tion.
DISCUSSION
REFERENCES Subdural empyema has become a relatively rare intracranial suppurative disease with the advent of BHANDARI, Y. S., and SARKARI, N. E. S., 1970. Subdural empyema. Journal ofNeurosurgery, 32, 35—39. antibiotics. The mortality rate has dropped from FERRIS, E. J., and LEVINE, H. L., 1973. Cerebral arteritis: nearly 100% to a current rate of 30% (Bhandari and classification. Radiology, 109, 327-341. Sarkari, 1970). Paranasal sinus infections are now FERRIS, E. J., RUDIKOFF, J. C , and SHAPIRO, J. H., 1968. Cerebral angiography of bacterial infection. Radiology, 90, the most common source followed by otitis media. 727-734. Non-haemolytic streptococcus is the most frequent GREITZ, T., 1964. Angiography in tuberculous meningitis. Acta Radiologica, {Diagnostic) 2, 369-378. offending organism (Bhandari and Sarkari, 1970). NEWTON, T. H., and COUCH, R. S. C , 1960. Possible errors Subdural empyema is a surgical emergency and in the arteriographic diagnosis of internal carotid artery early diagnosis vital. occusion. Radiology, 75, 766-773.
914
NOVEMBER
1978
Case reports Non-thrombotic occlusion of the cavernous carotid from subdurai empyema By R. W. Katzberg, M.D.* and G. Griffiths, M.B., B.C.H., D.C.H., F.R.C.R.f Department of Diagnostic Radiology, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642. {Received August, 1976 and in revisedform April, 1978)
Scattered reports of the significant angiographic findings in intracranial bacterial infection have demonstrated several types of vascular changes, many of which are non-specific. These include narrowing or spasm of the major vessels at the base of the brain, segmental arterial dilatation, peripheral arterial occlusions, aneurysmal formation due to vessel wall involvement by infection, arterio-venous shunting and a thickened vascular wall of the dura (Ferris et ah, 1968). The angiographic appearance of narrowing of a vessel may result from cellular infiltration, oedema of the wall, extrinsic compression or irritability of the vessel wall with actual vasospasm •Present address: Wilford Hall, USAF Medical Center/ SGHR Lackland AFB, Texas 78236. fPresent address: Department of Radiology, Royal Gwent Hospital, Newport, Gwent.
(Ferris and Levine, 1973). Progression of these changes to non-thrombotic occlusion has been observed in the smaller arteries of the brain. This is the first case demonstrating radiographic and pathologic documentation of non-thrombotic occlusion of the internal carotid artery secondary to intracranial infection. CASE HISTORY
A nine-month old female infant was admitted to Strong Memorial Hospital with a seven day history of upper respiratory infection, fever, and a purulent discharge from the left external auditory canal. Physical examination disclosed oedema of the left side of the head, a right central eighth nerve palsy and a right hemiparesis, which developed into decerebrate posturing. A left subdurai tap showed clear cerebrospinal fluid under no pressure. There was no growth on culture of the blood, cerebrospinal fluid or ear drainage, but gram positive micrococci were noted in the latter. An angiogram showed no internal cerebral circulation to the left hemisphere after a left common carotid injection. A
FIG. 1. (A) Anteroposterior and (B) lateral subtraction views following a right common carotid injection showing a long segment of severe narrowing of the cavernous portion of the internal carotid artery.
913
VOL.
51, No. 611 Case reports
Vascular spasm frequently observed with intracranial bacterial infection presumably is the result of irritation to the arterial wall from the surrounding inflammatory material, causing luminal narrowing (Ferris et al., 1968). Structural changes result from inflammatory involvement of the vessel wall itself with resultant intimal proliferations and inflammatory cells in all layers (Greitz, 1964). There are variable degrees of fibrosis with acute and chronic cellular infiltrates in the subarachnoid space. Progressive narrowing of the lumen leads to thrombosis with occlusion. Complete arterial occlusion without thrombosis has been reported to occur in various segments of the intracranial circulation, usually peripherally (Ferris FIG. 2. and Levine, 1973). Failure to fill the internal carotid High power photomicrograph of the left cavernous carotid artery has been described in cases of raised intraartery which shows marked luminal narrowing associated with mild intimal thickening and polymorphonuclear cells cranial pressure and termed "pseudo-occlusion" (Newton and Couch, 1960). This case is exceptional in the adventitia. in that it is the first report of non-thrombotic long segment of severe narrowing affecting mainly the occlusion of the vascular supply to an entire cerebral cavernous portion of the right internal carotid artery was hemisphere not resulting from increased intraalso demonstrated (Fig. 1). The circulation time was cranial pressure. markedly prolonged. Pathologic correlation of the left internal carotid The patient continued to deteriorate and the following day had a cardiac arrest and died. demonstrates acute inflammatory cells in the advenAt post-mortem examination a subdural empyema of the left middle cranial fossa was found with bilateral septic titia with only mild intimal thickening. The contrathrombosis of the cavernous sinuses resulting from a left lateral cavernous carotid shows changes of focal inotitis media and acute osteomyelitis of the left petrous timal thickening without inflammatory cellular inbone. Microscopy demonstrated severe stenosis of the left cavernous carotid artery without thrombosis and with poly- filtrations. This appearance is similar to that in early morphonuclear infiltration of the adventitia (Fig. 2), The atherosclerosis of the mature circulatory system. The intima was slightly thickened and the vascular lumen marked angiographic findings are disproportionate measured 66 microns. The lumen of the right cavernous carotid artery was 600 microns in diameter with focal intimal to the microscopic structural alterations and this thickening and acute and chronic peri-adventitial inflamma- may implicate spasm as a major modifying factor. tion.
DISCUSSION
REFERENCES Subdural empyema has become a relatively rare intracranial suppurative disease with the advent of BHANDARI, Y. S., and SARKARI, N. E. S., 1970. Subdural empyema. Journal ofNeurosurgery, 32, 35—39. antibiotics. The mortality rate has dropped from FERRIS, E. J., and LEVINE, H. L., 1973. Cerebral arteritis: nearly 100% to a current rate of 30% (Bhandari and classification. Radiology, 109, 327-341. Sarkari, 1970). Paranasal sinus infections are now FERRIS, E. J., RUDIKOFF, J. C , and SHAPIRO, J. H., 1968. Cerebral angiography of bacterial infection. Radiology, 90, the most common source followed by otitis media. 727-734. Non-haemolytic streptococcus is the most frequent GREITZ, T., 1964. Angiography in tuberculous meningitis. Acta Radiologica, {Diagnostic) 2, 369-378. offending organism (Bhandari and Sarkari, 1970). NEWTON, T. H., and COUCH, R. S. C , 1960. Possible errors Subdural empyema is a surgical emergency and in the arteriographic diagnosis of internal carotid artery early diagnosis vital. occusion. Radiology, 75, 766-773.
914
