Indian J Pediat 50: 457-459, 1983

Cavernous sinus thrombosis with retrobulbar
mass and hemiplegia
R. Rodrlgues, M.D., R. Merchant, M.D. and $. Parekh, M.R.C.P.
The clinical course and investigations of a three year old child who developed cavernous
sinus thrombosis are presented, and the problems in the diagnosis and management
highlighted. The peculiar features of this case were the presence of a retrobulbar mass and
hemiplegia.

Key words: Cavernous sinus thrombosis; retrobulbar mass; hemiplegla.

Cavernous sinus thrombosis (CST) is not
an uncommon entity in children. Before the
antibiotic era the condition was uniformly
fatal, while currently reported mortality is
about 25 percent in treated cases. I It was first
described by Abercrombie (1818) and
Duncan (1821). 2 The cavernous sinus has
numerous connections with the face, eyes,
sinuses, mastoid, middle ear, pituitary, cerebruin, cerebellum as well as the opposite
cavernous sinus, thus allowing for an easy
spread of infection. In most reported cases
the face is the primary site of infection and
the commonest organism isolated is Stap h y l o c o c c u s aureus, s The complications
encountered are blindness, cranial nerve
palsies, meningitis, subdural empyema,
hypopituitarism4 and metastatic spread of
infection to other organs.

Case report
A three year old female child who had
previously been in good health, presented
with a boil in the right nostril and high fever,
followed by a progressive swelling of the
right eye. On the seventh clay of fever she
developed weakness of the left side of the
body and a facial asymmetry. There was no
Bai Jerbai Wadia Children's Hospital and Institute of
Child Health, Parel, Bombay-400 0022.
Reprint requests: Dr. R. Merchant, Hon. Associate
Pediatrician

history to suggest sinusitis, ear discharge,
trauma or involvement of the other eye. On
examination she was conscious, febrile and
highly irritable. There was marked proptosis,
chemosis and sub conjunctival haemorrhage, a fixed dilated pupil, ptosis and
complete ophthalmoplegia of the right eye~
There was no audible bruit. Examination of
the left eye revealed no abnormality. The
child had a dense left hemiparesis, left facial
weakness, neck stiffness and a positive
Kerning's sign.
The hemoglobin was 8.0 gms/dl, total
white cell count was 9200/cu mm with 68
percent polymorphs, 30 percent lymphocytes and 2 percent eosinophils. The chest
and skull radiographs were normal. The
cerebrospinal fluid (CSF) on admission was
turbid with 500 cells, 60 mg percent proteins
and 36 mg percent sugar. After two weeks of
treatment the CSF was clear with 18 cells, 40
mg percent proteins and 56 mg percent sugar.
CSF and blood cultures were sterile. A radioisotope brain scan with dynamic cerebral
blood flow studies showed absent perfusion
of right middle cerebral artery (MCA) and a
large area of abnormal concentration triangular in shape corresponding to the area
supplied by the MCA. The electro-encephalogram showed marked asymmetry of electrical
activity with decreased activity on the right
side, particularly the temporal area consistent with a state of cerebral infarction.

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THE INDIAN JOURNAL OF PEDIATRICS

Ultrasound of the right eye revealed a retrobulbar, sonolucent mass of 1.2 cms size with
well defined borders. The optic nerve, retina
and lens appeared normal. The computerised tomography (CT) scan reported a very
large infarct in the peripheral portion on the
right cerebral hemisphere (Fig. I) and a
highly attenuated retrobulbar mass (Fig. 2).

The patient after admission was treated
with high doses of parenteral antibiotics
along with usual supportive therapy. Anticoagulants were not administered at any
time. She showed a gradual improvement in
clinical status and made an uneventful
recovery. Six weeks later there was reduction in the proptosis, the ophthalmoplegia
had disappeared, the pupil was reacting to
light and the power on the left side had
improved.
Discussion

Fig. 1. The CT scan which shows a massive infarct in
the periphery of the right cerebral hemisphere.

Fig. 2. The presence of proptosis and a retrobulbar
mass on the right side can be appreciated on this
section of the CT scan.

The child we have described exhibited the
classical sequence of events one sees in CST,
namely a primary infection in the nose
followed by signs of involvement of the
cavernous sinus on the same side. There
were two unusual features in this case, the
retrobulbar mass and the hemiplegia. The
retrobulbar mass was detected by both the
ultrasound as well as the CT scan. A differential diagnosis of retrobuibar edema or
abscess was considered. We were unable to
come across references of ultrasound of the
eye in CST and were in a dilemma as what to
do. At this time the child's condition had
settled, she appeared to be recovering and
hence we decided to follow a course of
watchful expectancy. This paid dividends as
shown by the outcome of the disease.
Hemiplegia is a fairly unusual presentation in CST and in most cases is due to
involvement of the internal carotid artery.
Although internal carotid arteritis is a
common entity in children, CST as a cause of
this is quite rare. A case of CST with involvement of the carotid artery and a vascular
steal syndrome has been described, s Our
case in all probability had involvement of the
internal carotid artery and this could have
been confirmed by carotid angiography. In
view of the invasiveness of the procedure
and the fact that other non-invasive techniques had provided adequate information,
we did not do a carotid angiogram.

RODRIGUES ET AL: CAVERNOUS SINUS THROMBOSIS

References
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cavernous sinus thrombosis. Arch Ophth 96: 453,
1978
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Med $ci 24: 748, 1970

459
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4. Oliven A, Hotel D, Rosenfeld T, Spindel A, GidronE:
Hypopituitarism after aseptic cavernous sinus thrombosis. Neurology 30: 897, 1980
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