Intracranial complications of sinusitis and mastoiditis in children: imaging spectrum

Intracranial complications of sinusitis and mastoiditis in children: imaging spectrum Poster No.: R-0098 Congress: RANZCR ASM 2013 Type: Scientific Exhibit Authors: L. L. Wang, J. Leach; Cincinnati/US Keywords: Ear / Nose / Throat, Head and neck, Pediatric, CT, MR, MRAngiography, Abscess delineation, Infection, Ischemia / Infarction, Abscess DOI: 10.1594/ranzcr2013/R-0098 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. www.ranzcr.edu.au Page 1 of 69

Purpose Sinusitis and mastoiditis are common diseases in the pediatric population. Intracranial complications are infrequent, but can be serious and even fatal. Clinical presentation and laboratory findings alone are often not sufficient for detection. Imaging plays a key role in workup and management, especially in the pediatric population when the presenting symptoms may be vague and non-localizing. Radiologists should be aware of the imaging spectrum of these conditions as early detection can help prevent serious sequelae. Methods and Materials The study was approved by the hospital's institutional review board. A Radiology Information System search was performed for all CT and MRI reports containing positive findings of 'sinusitis' or 'mastoiditis', AND 'abscess', 'empyema', 'thrombophlebitis', 'venous thrombosis', 'venous infarct/infarction', 'infarction', 'meningitis' or 'cerebritis' from 1996-2011. Medical record review was performed on identified cases. Cases where sinusitis/mastoiditis were not the cause of the intracranial pathology were excluded. All imaging of the final cohort was reviewed. Results 51 cases were identified. Complications of sinusitis included: epidural empyema, subdural collection, cerebritis, cerebral abscess, thrombophlebitis, dural venous sinus thrombosis/infarction and meningitis. Complications of mastoiditis included: epidural empyema, subdural collection, meningitis, cerebritis, dural venous sinus thrombosis and meningitis. There were 21 epidural and 7 infected subdural collections. Two brain abscesses and 10 cases of associated cerebritis were identified. Venous sinus complications include thrombophlebitis and dural venous sinus thrombosis (14) and venous ischemia/infarction (4). Key imaging features of each of these entities will be presented and discussed. Treatment issues and how they relate to imaging findings will be emphasized. Imaging Findings 1. Complications of Sinusitis A. Collections Page 2 of 69

Epidural Abscess Epidural abscesses are the most prevalent intracranial complication of sinusitis in our series, mostly associated with frontal sinusitis in the anterior cranial fossa. Mechanism Submucosal venous net -> Breschet veins -> Diploe -> Epidural space Presentation Headache, mental status change. May be minimally symptomatic. Two patients presented with preceding trauma and low-grade fever, complicating the interpretation of the study. Typical Organism Staphylococcus Treatment Surgical drainage of sinus and abscess. Antibiotics. Page 3 of 69

Fig. 4: Epidural Imaging Fig. 1: 11 year old female with frontal sinusitis and facial swelling. CT with contrast shows a focal midline fluid collection (purple) and bony dehiscence (red) (osteomyelitis). There is a frontal subgaleal abscess (blue) (Pott's puffy tumor) which communicates with it. Fig. 2: 19 year old female presented with left sided weakness. Had head trauma. There are frontal epidural abscesses (red) bilaterally. These were misinterpreted initially as 'hematomas'. There is restricted diffusion (purple). Page 4 of 69

Fig. 3: 8 year old female with frontal sinusitis and post-septal cellulitis. Four days after initial presentation, CT and MRI show an epidural abscess (red). There is no restricted diffusion (purple) in this case. This is not as common. Subdural Empyema This is the most prevalent intracranial complication of sinusitis reported, commonly associated with frontal sinusitis. Mechanism Progressive thrombophlebitis through mucosal veins to emissary veins and extra-axial space. Presentation Headache, mental status change and fever. Typical Organism Streptococcus Treatment Delay in treatment can be fatal. Identification of a subdural collection, and its complications, in the setting of sinus disease and appropriate clinical presentation is an ENT and Neurosurgical emergency. Combined approach of emergent sinus drainage, close neurosurgical observation and craniotomy in selected cases. Page 5 of 69

Fig. 5: Subdural Imaging Page 6 of 69

Fig. 11: 17 year old male with altered mental status and syncope, recently treated for sinusitis for several days. Non contrast CT shows a left subdural fluid collection (purple), soft tissue swelling (red) (Pott's puffy tumor) and midline shift to the right. There is also diffuse cerebral edema. Page 7 of 69

Fig. 12: 2 cases of interhemispheric subdural empyema (red). Spread is typically limited by the falx. The case on the right has an associated subgaleal fluid collection (purple). Fig. 13: 15 year old male with pansinusitis developed an interhemispheric subdural collection (red), meningitis and diffuse cerebral edema, requiring craniectomy and drainage. The subdural increased in size, with herniation of brain (purple) through the craniectomy defect on day 4. This eventually resolved with further drainage. Page 8 of 69

Fig. 14: There is a small parafalcine subdural collection (purple) in this 7 year old female who presented with facial pain. This can be easily missed on CT. The patient had surgical drainage of collection. Cerebral Abscess Frontal cerebral abscesses most commonly are related to epidural and subdural collections secondary to frontal sinusitis. Abscess elsewhere is rare. Higher incidence is seen in adolescents and young adults. Presentation Mental status change, fever, headache, seizure. Mechanism Probable direct extension from subdural space Typical Organism Staphylococcus Treatment Empiric antibiotic treatment. Surgical evacuation for larger abscesses. Smaller ones can be treated with antibiotics with imaging follow up. Fig. 15: 12 year female presented with headaches, fever and confusion. There is pan-sinus opacification (not shown). The initial CT showed an area of hyperdense foci surrounded by a hypodense area. CT on day 6 showed a well-defined abscess (red) with surrounding vasogenic edema (purple). Page 9 of 69

Fig. 16: 11 year old female with headaches, left orbital swelling and fever. The initial CT (not shown) showed pan-sinusitis and basilar meningitis. Her mental status deteriorated, requiring intubation and ventilation. CT and MRI on day 7 showed rhombenmesencephalitis with extension of an abscess into the left brachium pontis (arrow). Page 10 of 69

Fig. 17: 15 year old male status post drainage of frontal abscess secondary to sinusitis. CT on day 1 shows moderate adjacent vasogenic edema (purple) extending to the basal ganglia and internal capsule. The MRI on day 6 with contrast shows persistent parenchymal enhancement (red), consistent with persistent cerebritis but with reduced edema. B. Vascular Complications Venous Complications Venous sinus thromboses are rare but severe complications. This may be a late complication. Cavernous sinus (CS) and superior sagittal sinus (SSS) are the most common sites. Presentation Eye signs such as proptosis, headache, altered mental status are most common. Mechanism Superficial thrombophlebitis -> Drainage into deep venous sinuses -> Deep venous thrombosis Treatment Empiric antibiotics. Anticoagulation. Page 11 of 69

Fig. 6: Venous Complication Imaging Page 12 of 69

Fig. 18: 9 year old male with right eye swelling and pan-sinusitis. MRI shows filling defects (arrows) in bilateral CSs, consistent with thrombosis, which has 30% mortality and 60% morbidity in adults. Page 13 of 69

Fig. 19: 14 year old obtunded male with pan-sinusitis, requiring intubation. CT with contrast shows SOV thrombophlebitis (red) and bilateral CS thrombosis (bowing of sinuses (purple) with filling defects). Fig. 20: 13 year old with SSS thrombosis (arrows) secondary to frontal sinusitis. SSS thrombosis is not an uncommon complication of frontal sinusitis in our series. Although MRI may better depict parenchymal complications, CTV is very useful to identify venous thrombosis and can be performed at the time of initial imaging. Arterial Complications This devastating complication was more common in the pre-antibiotic era. Most commonly due to sphenoid sinusitis. Septic embolism is very rare. Vasospasm, pseudoaneurysms and mycotic aneurysms may form, in some cases requiring surgical therapy. Presentation Mental status change, stroke signs & symptoms. Sinus symptoms may be absent (especially sphenoid). Mechanism Vasospasm or vasculitis. Pseudoaneurysm or mycotic aneurysm. Treatment Antibiotics. Anticoagulation. Page 14 of 69

Fig. 21: 17 year old unresponsive male. Initial head CT showed pneumocranium (red), hydrocephalus, cerebral edema and sphenoid sinusitis. Subsequent MRI the next day showed diffuse narrowing of the vessels of the circle of Willis, presumably diffuse vasospasm or vasculitis and meningeal enhancement (purple). He had progressive neurological decline. CT on day 5 showed extensive multi-territorial infarction (blue) and cerebral edema with uncal herniation. Fig. 22: 15 year old male with left thalamic (red) and left pontine (purple) infarction from pan-sinusitis, meningitis, cavernous sinus thrombosis and basilar artery vasospasm/occlusion. MRA shows an attenuated basilar artery (blue), as well as left posterior cerebral artery (blue). Other Complications of Sinusitis Meningitis Typically associated with frontal or ethmoid sinusitis. More common in young children. Seizure is the most common sequela. Presentation Signs & symptoms of meningism. Change in mental status. Mechanism Hematogenous spread typically Typical Organisms Streptococcus and Haemophilus influenzae type B Page 15 of 69

Treatment Endoscopic sinus surgery. Empiric antibiotic treatment. Clinical management. Lumbar puncture performed to identify organism. Fig. 8: Meningitis Imaging Page 16 of 69

Fig. 23: Mildly diffusely increased leptomeningeal enhancement with cerebral edema, lumbar puncture findings consistent with meningitis. Page 17 of 69

Fig. 24: Focal perimesencephalic and interpeduncular leptomeningeal enhancement (arrow), same patient as above, with pontine infarction. Page 18 of 69

Cerebritis Cerebritis is very common in association with epidural empyema from frontal sinusitis. Presentation Mental status change, stroke. Mechanism As per cerebral abscess. Direct irritation by collection. Treatment Empiric antibiotic treatment. Fig. 9: Cerebritis Imaging Page 19 of 69

Fig. 25: 14 year old male with frontal sinusitis, Pott's puffy tumor (red) on day 1, developed small epidural abscess (purple) with adjacent cerebritis (blue) on CT and MRI performed on day 7. The patient was treated with IV antibiotics. CT at 5 weeks shows complete resolution of cerebritis and edema. Page 20 of 69

Fig. 32: 17 year old male with complications from frontal sinusitis, developed an area of low attenuation and loss of grey/white matter differentiation (arrow) on CT. Page 21 of 69

Fig. 33: MRI in the same patient at 4 weeks shows thick cortical enhancement (arrow) with restricted diffusion (not shown). This evolved into an area of encephalomalacia on follow up. Venous infarction is a differential diagnosis. Petechial Hemorrhage This complication is most likely related to cerebritis or venous infarction. Page 22 of 69

Fig. 34: 7 year old male presented with fever, vomiting, lethargy and dilated pupil. Non contrast CT shows punctate hyperattenuating foci (arrow) and diffuse cerebral edema. The changes in the frontal lobe are presumably hemorrhagic cerebritis or sequela of venous thrombosis. Follow-up contrast CT after craniectomy shows a new small contralateral subdural collection. Hydrocephalus Hydrocephalus may result from impaired CSF resorption from associated meningitis or venous occlusion. Page 23 of 69

Fig. 35: Obstructive hydrocephalus in a 17 year old with pansinusitis. Page 24 of 69

Fig. 36: Obstructive hydrocephalus shunted but recurred in an 11 year old female with frontal sinusitis complicated by cerebritis, cavernous sinus thrombosis and meningitis. Herniation Page 25 of 69

Fig. 37: Uncal herniation (arrow) from frontotemproal empyema. Page 26 of 69

Fig. 38: Subfalcine herniation (red) from frontal empyema (blue). 2. Complications of Mastoiditis Acute otitis media (OM) is more common in a younger age group compared to paranasal sinusitis. While OM is usually a clinical diagnosis, imaging should be performed in patients with persistent symptoms despite antibiotic treatment. Presentation Otalgia, erythema, fever, headache and otorrhea Typical Organism Haemophilus influenzae type B Mechanism OM -> Blocked aditus ad antrum -> Fluid trapping -> Mastoiditis -> Osteomyelitis -> Direct/venous intracranial spread -> Epidural abscess -> Dural venous sinus thrombosis Treatment Antibiotics. Mastoidectomy. Drainage. Anticoagulation for thrombosis. Page 27 of 69

Fig. 10: Mastoiditis Imaging A. Collections Epidural Abscess There is an epidural abscess with a pocket of gas and a small subcutaneous abscess. The sigmoid sinus is displaced medially. Can be clinically silent. Commonly a precursor of dural venous sinus thrombosis. Page 28 of 69

Fig. 26: There is an epidural abscess with a pocket of gas and a small subcutaneous abscess. The sigmoid sinus is displaced medially. Page 29 of 69

Fig. 27: 15 year old male with epidural abscess with an air-fluid level, separate from the sigmoid sinus. The sigmoid sinus was thrombosed. Page 30 of 69

Fig. 28: 6 year old male with a small fluid collection (red) displacing/effacing the sigmoid sinus. There is a small subcutaneous fluid collection (blue). Bone window shows frank dehiscence (purple) of sigmoid cortical plate and mastoid opacification. B. Vascular Complications Venous Complications Transverse sinus, sigmoid sinuses and internal jugular vein are the common veins to be involved. Typically, thrombophlebitis propagates on the same side as the mastoiditis. Bilateral thrombosis is very rare. Page 31 of 69

Fig. 29: There is an epidural abscess (red) with a pocket of gas and a small subperiosteal abscess. The adjacent sigmoid sinus was markedly compressed and there was a filling defect (purple) within the jugular bulb and distal transverse sinus consistent with thrombosis. Page 32 of 69

Fig. 30: 6 year old male. CT shows an epidural collection (red) compressing the left transverse sinus. Thrombosis of the transverse and sigmoid sinuses and internal jugular vein is confirmed on MRV as an area of signal loss (green). MRI shows a T1 hyperintense thrombus (purple) and intrasinus filling defect (blue) on post contrast imaging. Page 33 of 69

Fig. 31: 10 year old male with vomiting, ear pain and headache. CT shows an enhancing wall with a filling defect (purple) consistent with a thrombus in the left IJV. A small soft tissue abscess (red) is also identified to the left of the lateral mass of C1. Page 34 of 69

There is frank dehiscence (blue) of the cortical plate adjacent to the right sigmoid sinus. MRI shows left IJV thrombophlebitis, transverse and sigmoid sinus thrombosis with adjacent soft tissue enhancement. Images for this section: Fig. 1: 11 year old female with frontal sinusitis and facial swelling. CT with contrast shows a focal midline fluid collection (purple) and bony dehiscence (red) (osteomyelitis). There is a frontal subgaleal abscess (blue) (Pott's puffy tumor) which communicates with it. Fig. 2: 19 year old female presented with left sided weakness. Had head trauma. There are frontal epidural abscesses (red) bilaterally. These were misinterpreted initially as 'hematomas'. There is restricted diffusion (purple). Page 35 of 69

Fig. 39 Page 37 of 69

Fig. 5: Subdural Imaging Page 38 of 69

Fig. 6: Venous Complication Imaging Page 39 of 69

Fig. 7: Arterial Complication Imaging Page 40 of 69

Fig. 8: Meningitis Imaging Page 41 of 69

Fig. 9: Cerebritis Imaging Page 42 of 69

Fig. 41 Page 43 of 69

Fig. 15: 12 year female presented with headaches, fever and confusion. There is pansinus opacification (not shown). The initial CT showed an area of hyperdense foci surrounded by a hypodense area. CT on day 6 showed a well-defined abscess (red) with surrounding vasogenic edema (purple). Page 46 of 69

Fig. 19: 14 year old obtunded male with pan-sinusitis, requiring intubation. CT with contrast shows SOV thrombophlebitis (red) and bilateral CS thrombosis (bowing of sinuses (purple) with filling defects). Fig. 20: 13 year old with SSS thrombosis (arrows) secondary to frontal sinusitis. SSS thrombosis is not an uncommon complication of frontal sinusitis in our series. Although MRI may better depict parenchymal complications, CTV is very useful to identify venous thrombosis and can be performed at the time of initial imaging. Fig. 21: 17 year old unresponsive male. Initial head CT showed pneumocranium (red), hydrocephalus, cerebral edema and sphenoid sinusitis. Subsequent MRI the next day showed diffuse narrowing of the vessels of the circle of Willis, presumably diffuse vasospasm or vasculitis and meningeal enhancement (purple). He had progressive neurological decline. CT on day 5 showed extensive multi-territorial infarction (blue) and cerebral edema with uncal herniation. Page 50 of 69

Fig. 40 Page 51 of 69

Fig. 23: Mildly diffusely increased leptomeningeal enhancement with cerebral edema, lumbar puncture findings consistent with meningitis. Page 52 of 69

Fig. 24: Focal perimesencephalic and interpeduncular leptomeningeal enhancement (arrow), same patient as above, with pontine infarction. Page 53 of 69

Fig. 26: There is an epidural abscess with a pocket of gas and a small subcutaneous abscess. The sigmoid sinus is displaced medially. Page 55 of 69

Fig. 27: 15 year old male with epidural abscess with an air-fluid level, separate from the sigmoid sinus. The sigmoid sinus was thrombosed. Page 56 of 69

dehiscence (blue) of the cortical plate adjacent to the right sigmoid sinus. MRI shows left IJV thrombophlebitis, transverse and sigmoid sinus thrombosis with adjacent soft tissue enhancement. Page 61 of 69

Fig. 32: 17 year old male with complications from frontal sinusitis, developed an area of low attenuation and loss of grey/white matter differentiation (arrow) on CT. Fig. 33: MRI in the same patient at 4 weeks shows thick cortical enhancement (arrow) with restricted diffusion (not shown). This evolved into an area of encephalomalacia on follow up. Venous infarction is a differential diagnosis. Page 62 of 69

Fig. 35: Obstructive hydrocephalus in a 17 year old with pansinusitis. Page 64 of 69

Fig. 36: Obstructive hydrocephalus shunted but recurred in an 11 year old female with frontal sinusitis complicated by cerebritis, cavernous sinus thrombosis and meningitis. Page 65 of 69

Fig. 37: Uncal herniation (arrow) from frontotemproal empyema. Page 66 of 69

Fig. 38: Subfalcine herniation (red) from frontal empyema (blue). Page 67 of 69

Conclusion It is critical that radiologists accurately identify the intracranial complications of sinusitis and mastoiditis in children. Knowledge of the imaging spectrum and how imaging findings relate to treatment options is important for best patient care. Personal Information Lily Wang, MBBS, MPH, FRANZCR Fellow, Neuroradiology, University of Cincinnati James Leach, MD Associate Professor, Neuroradiology, Cincinnati Children's Hospital Medical Center References Bayonne, E., R. Kania, et al. (2009). "Intracranial complications of rhinosinusitis. A review, typical imaging data and algorithm of management." Rhinology 47(1): 59-65. Broberg, T., A. Murr, et al. (1999). "Devastating complications of acute pediatric bacterial sinusitis." Otolaryngol Head Neck Surg 120(4): 575-579. Giannoni, C., M. Sulek, et al. (1998). "Intracranial complications of sinusitis: a pediatric series." Am J Rhinol 12(3): 173-178. Goldberg, A. N., G. Oroszlan, et al. (2001). "Complications of frontal sinusitis and their management." Otolaryngol Clin North Am 34(1): 211-225. Jones, N. S., J. L. Walker, et al. (2002). "The intracranial complications of rhinosinusitis: can they be prevented?" Laryngoscope 112(1): 59-63. Kastner, J., M. Taudy, et al. (2010). "Orbital and intracranial complications after acute rhinosinusitis." Rhinology 48(4): 457-461. Kombogiorgas, D., R. Seth, et al. (2007). "Suppurative intracranial complications of sinusitis in adolescence. Single institute experience and review of literature." Br J Neurosurg 21(6): 603-609. Kuczkowski, J., W. Narozny, et al. (2005). "Suppurative complications of frontal sinusitis in children." Clin Pediatr (Phila) 44(8): 675-682. Page 68 of 69

Sultesz, M., Z. Csakanyi, et al. (2009). "Acute bacterial rhinosinusitis and its complications in our pediatric otolaryngological department between 1997 and 2006." Int J Pediatr Otorhinolaryngol 73(11): 1507-1512. Vazquez, E., A. Castellote, et al. (2003). "Imaging of complications of acute mastoiditis in children." Radiographics 23(2): 359-372. Vazquez, E., S. Creixell, et al. (2004). "Complicated acute pediatric bacterial sinusitis: Imaging updated approach." Curr Probl Diagn Radiol 33(3): 127-145. Younis, R. T., V. K. Anand, et al. (2001). "Sinusitis complicated by meningitis: current management." Laryngoscope 111(8): 1338-1342. Page 69 of 69