Kosin Med J.  2018 Dec;33(3):454-462. 10.7180/kmj.2018.33.3.454.

A Case Of Cavernous Sinus Syndrome and Mutifocal Cerebral Infarction Related To Mucormycosis Of Sphenoid Sinus

• Jeon SW
• Kim CH
• Kim JY
• Kwon JH

• KMID: 2442559
• DOI: http://doi.org/10.7180/kmj.2018.33.3.454

Abstract

A 54-year-old man, suffering from severe headache and ophthalmoplegia after undergoing endoscopic sinus surgery was referred to a tertiary hospital. Computed tomography (CT) revealed soft tissue density lesions in the left sphenoid sinus. The internal carotid artery was shown to be occluded in brain magnetic resonance imaging (MRI) scans without any other cerebral lesion. Endoscopic view of left nasal cavity shows whitish hyphae in the ethmoid and the sphenoid sinuses. We diagnosed him with cavernous sinus syndrome caused by mucormycosis and conducted endoscopic sinus surgery to remove remaining lesions and decompress orbit and optic nerves. After the revision surgery the patient's headache and ophthalmoplegia were improved. However, multifocal cerebral infarctions were newly discovered in a postoperative CT scan. We experienced a case of mucormycosis of sphenoid sinus resulting in occlusion of internal carotid artery and multifocal cerebral infarction, and report it with a brief review of these disease entities.

Keyword

Cavernous sinus; Cerebral infarction; Mucormycosis

MeSH Terms

Brain
Carotid Artery, Internal
Cavernous Sinus*
Cerebral Infarction*
Headache
Humans
Hyphae
Magnetic Resonance Imaging
Middle Aged
Mucormycosis*
Nasal Cavity
Ophthalmoplegia
Optic Nerve
Orbit
Sphenoid Sinus*
Tertiary Care Centers
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Preoperative axial computed tomography (CT) and magnetic resonance images (MRI) show left sphenoid sinus lesion. Arrow heads indicates left sphenoid sinus in both images.

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  Fig. 2 These are postoperative extraocular movements of the patient. A. Patient showed ptosis and ophthalmoplegia of his left eye in all directions after endoscopic sinus surgery. B. 6 months after revision operation, patient's ptosis and ophthalmoplegia had been improved partially when gazing medially.

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  Fig. 3 Both endoscopic and histologic findings revealed fungal infection after the first surgery in another hospital. A. Endoscopic finding of left nasal cavity shows fungal hyphae and crust around posterior ethmoid sinus and sphenoid sinus before revision surgery. arrowhead : left sphenoid sinus, arrow : lamina papyracea B. Histopathologic scan shows non-septated, right angled branched hyphae (H&E stain, × 400).

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  Fig. 4 Computed tomography (CT) and magnetic resonance images (MRI) were taken before revision surgery. A. CT scan shows heterogenous enhancing lesion involving orbital apex (black arrow). B. White arrow indicates occlusion of left carotid artery in MRI.

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  Fig. 5 These pictures are presenting brief intraoperative findings during revision surgery. A. Most of the area between lamina papyracea and sphenoid sinus was covered with granulomatous necrotic tissues. asterisk : middle turbinate, arrow head : sphenoid sinus, arrow : lamina papyracea B. Magnified view of left sphenoid sinus C. Black Circle indicates the site conducted partial optic nerve decompression. D. Absorbable material (Surgicel®) was applied to prevent bleeding.

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  Fig. 6 Brain magnetic resonance images (MRI) and MR angiography were taken after revision surgery. A. MR angiography cannot visualize left anterior cerebral artery, middle cerebral artery and ICA (white arrow). B. Brain MRI shows infarction of left parietal lobe (white circle).

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