Brain abscess - an unusual complication of cavernous
sinus thrombosis
A ease report

A.K.

Mahapatra*

Introduction
Cavernous sinus thrombosis is a well known
complication of facial, paranasal sinus and dental infection’*‘. Brain abscess as a complication
of C.S.T. is well known but rare, and appears in
the literature as case reports”“. In this paper
such a case is reported where C.S.T. was most
likely the cause of the brain abscess.

An unusual case of multilocular brain abscess
is reported in a lCyear-old girl, following cavernous sinus thrombosis. In absence of any
other source of infection the cavernous sinus
thrombosis is presumed as the cause of brain
abscess. Possible pathogenesis is discussed.
Key words: Facial infection, cavernous
thrombosis (C.S.T.), brain abscess.

Case report
A l4-year-old girl was admitted to our unit with
a history of headache and vomiting for 3 months
and left frontal scalp swelling of one month duration. Eight months prior to admission she had
a furuncle over the nose on the left side, which
ruptured and discharged pus. Ten days later she
developed high grade fever ranging from
102”-103”F, left sided proptosis and blurring of
vision. There was conjunctival injection and periorbital swelling. The diagnosis of septic thrombophlebitis of the cavernous sinus was made,
and the patient was treated at a civil hospital and
made a good recovery. She remained well for
next 3 months.
On admission she was conscious, oriented but
had bilateral papilledema. She also had left sided third and sixth nerve paresis. Left eye was
proptosed with periorbital oedema. There was
small scalp swelling over the left posterior frontal region. There was no other site of infection.
She had no history of acute or chronic ear dis* Department

Summary

of neurosurgery,

Address for correspondence
India

All lndia I~tit~e

sinus

charge or congenital heart disease. Examination
of chest, cardiovascular system or abdomen revealed no abnormality.
Her haemoglobin was 14.6 gm% and total
leucocyte count was 64OO/cu mm. Plain radiograph of the skull was normal and paranasal
sinus view revealed no abnormality. A contrast
enhanced C.T. scan showed a multiloculated
left frontotemporal brain abscess with massive
oedema and midline shift to the rightside, and
scalp abscess overlaying the brain abscess (Fig.
la, b).
The patient was treated with intravenous
cloxacillin 500 mgs 8 hourly and Gentamycin 40
mg I/V eight hourly, however, patient deteriorated on seventh day after admission and became comatose. An emergency frontotemporal
craniotomy was performed and a left temporal
multilocular abscess was excised and left frontal

of Medical Science, New Dehli, lI~Z9,

India.

and reprint requests: A. K. Mahapatra, Department of Neurosurgery,

A.I. I. M. S. New Dehii, 110029,

Accepted 29.4.88
Clin Neural ~eurosurg

1988. Vol. 90-3

241

Fig. la. Contrast enhanced C.T. Scan shows lelt frontotcmporal multiloculated brain abscess with massive oedems and
midline shift to the right side

Fig. 2. Postoperative Contrast enhanced C.T. scan shows
residual left frontal abscess.

abscess was aspirated. As the brain was still
tense duraplasty was performed by using the
temporalis fascia. Postoperatively
antibiotics
were continued and dilantin 100 mg twice daily
was added. Pus culture grew Staphylococcus aureus and Proteus Merabillis, sensitive to Gentamycin and Cephalosporin,
hence Cioxacillin
was stopped and Cephalosporin was added.
Following surgery she developed right sided
hemiplegia and expressive dysphasia. A repeat
C.T. scan, performed one week following surgery (Fig. 2), showed residual left frontal abscess, which was subsequently reaspirated. Patient slowly improved over a period of 4 weeks
and on discharge she had mildexpressive dysphasia and 3/5right sided hemiparesis. On follow-up 3 months later her speech was normal.
however, she had 4/s hemiparesis on the right
side.
Discussion
Cavernous Sinus Thrombosis (CST) is a life
threatening condition first described by Ducan
in 1821’Oand usually results from midfacial in-

242

fection, paranasa1 sinusitis or dental infection4”.“.‘2. Prior to the invention of the penicillin
the mortality was lOO%, however, because of
the awareness of the condition and prompt action the mortality has come down significantly?
Intracranial infection is a well known complication following CST3,‘,‘. There are only a few
case reports of brain abscess as a complication of
CST’-‘,‘. Reports from India indicate that the
chronic otitis media is still the most common
cause of brain abscess and in about 20-25% of
the cases no source of the infection’s,1” is found.
In the present case there was neither CSOM nor
congenital heart disease. However, she definitely had CST 8 months prior to admission, while
she suffered from headache and vomiting 5
months prior. Usual time interval between CST
and development of a brain abscess has been
reported to vary from 3 months to 6 months4,
Hence CST as a possible cause of brain abscess
in present case has been considered. Various
modes of spread of infection from cavernous
sinus has been postulated
by many authorsJ+s,‘2*‘4,
and hematogenous spread is one of
them. In that case the left frontal scalp abscess
can well be explained by the hematogenous
spread from the previous infection of the cavernous sinus, due to inadequate treatment.
Thus the cause of the brain abscess in the present case as a consecture and CST is a distinct
possibility.
Common sites of the abscess described in the
literature are frontal and temporal lobes2-4*7.
Rarely cerebellar abscess has also been reported”. In our case the patient had a large frontotemporal multilocular abscess.
Staphylococcus aureu is the commonest organism responsible for CST and the brain abscess
following it4W7.‘z.t3.RareIy Proteus, Pseudomonas and Bacteroides have also been reported@*.
In the present case pus culture grew Staphylococcus aureus and Proteus Mirabillis. It is rare
to fnd two organisms.
The diagnosis of the brain abscess is easy, and
when fever continues and focal convulsion or
focal deficit appear after CST brain abscess
should be suspected4*7. Similar symptomato~ogy
could also be due to infarction in the brainr4. The
CT scan is invaluable in the diagnosis and follow-up of such Iesions1,‘4. In the present case CT

scan showed a muItiIocular brain abscess. Repeat CT scan post-operatively revealed residual
abscess which was subsequently aspirated.
Before the discovery of penicillin mortality in
cases of septic CST was as high as9~%-1~%~,‘~.
Yarington’ in a review of 878 cases of CST reported a mortality of 80%. however, his suhsequent analysis in 1977 showed a significant fall
in the mortaiity rate to 13.6%. This is largely
because of the high index of suspicion. early
diagnosis and the agressive treatment. In our
case, the patient made a good recovery. After
the surgery for multilocular brain abscess, however, she developed a right sided hemiplegia
and an expressive dysphasia. At the time of
discharge from the hospital, 4 weeks after surgery she started to speak a few words and her
power improved to 2-“/s. Follow-up 6 months
later showed a good recovery.
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