Wednesday, October 24, 2007

Cavernous Sinus Thrombosis(CST)

.

I was unwell 9 days prior to Eidil Fitri with severe headache which continued through my sleep in the form of dream. On the next day I requested for MRI but CT scan was done instead as it was been used on other scheduled patient. CT scan was negative of any significant findings.

As I had history of transphenoidal brain surgery recently and now having severe headache with nasal infection, they arranged me for late afternoon MRI. The diagnosis CST was made based on MRI findings and high TWBC count of more than 15K.

I was immediately started on i/v Rocephine 2g stat and 1g bid, Flagyl 500mg tid and Gentamycin 240mg dly. On top of that Iwas also given i/v Dexamethasone tid for 3 days and Zantac bid.

The headache disappeared by the next day without any analgesic. On the third day I started to experience the side effects of the antibiotics; nausea, giddiness and gastrointestinal discomforts. On the sixth day i had symptoms of hypopituitarism, the addisonian crisis. I started to pass urine every hour even at night, drowsy, lethargy, low pulse, nausea, abdominal discomfort, cold and heaviness of the head.

I was given i/v Hydrocortisone 200mg stat than 100mg bid. The symptoms improved a few hours later. I was discharged 2 days later with oral hydrocortisone, oral zinnat and zantac.

Alhamdulillah, I am recovering well with strong family support especially from my other significant half. I am grateful to God not only for giving me good recovery but getting me closer to Him, understanding myself better with the guide from a book written by Imam AlGhazali, The Alchemy of Happiness.

I am grateful to Allah for the support from my family, friends and the medical staff who help me to regain my health.




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Cavernous sinus thrombosis (CST) is usually a late complication of an infection of the central face or paranasal sinuses. Other causes include bacteremia, trauma, and infections of the ear or maxillary teeth. CST is generally a fulminant process with high rates of morbidity and mortality.

Prior to the advent of effective antimicrobial agents, the mortality rate from CST was effectively 100%.
Typically, death is due to sepsis or central nervous system (CNS) infection. With aggressive management, the mortality rate is now less than 30%.
Morbidity, however, remains high, and complete recovery is rare. Roughly one sixth of patients are left with some degree of visual impairment, and one half have cranial nerve deficits.

History: The early signs and symptoms of CST may not be specific. A patient who presents with headache and any cranial nerve findings should be potentially evaluated for CST.

* Patients generally have sinusitis or a midface infection eg pimples(squeezing of pimples).

* Headache is the most common presentation symptom and usually precedes fevers, periorbital edema, and cranial nerve signs.
The headache is usually sharp, increases progressively, and is usually localized to the regions innervated by the ophthalmic and maxillary branches of the fifth cranial nerve.

* As the infection tracts posteriorly, patients complain of orbital pain and fullness accompanied by periorbital edema and visual disturbances.

* Without effective therapy, signs appear in the contralateral eye by spreading through the communicating veins to the contralateral cavernous sinus. Eye swelling begins as a unilateral process and spreads to the other eye within 24-48 hours via the intercavernous sinuses. This is pathognomonic for CST.

* Patient rapidly develops mental status changes including confusion, drowsiness, and coma from CNS involvement and/or sepsis. Death follows shortly thereafter.

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