Cavernous sinus thrombosis: linking a swollen red eye and headache

A previously healthy 75-year-old woman presented in November, 2012, with a 10 day history of progressive headache, fatigue, and fever, and gradual onset periorbital oedema and reddish chemosis of the left eye. On examination she was alert and oriented without obvious neurological abnormalities. She had normal visual acuity and light reflex bilaterally. Eye movement was restricted on upward gaze of the left eye due to the oedema but was otherwise normal. The patient denied rhinorrhoea, but on nasal endoscopic examination in our otolaryngological clinic we saw purulent discharge from the orifice of the left sphenoidal sinus. She had a raised white blood cell count, C-reactive protein, and D-dimer. Contrast-enhanced CT of the paranasal sinuses and brain showed opacification of the left sphenoidal sinus, and filling defects of the left superior ophthalmic vein and cavernous sinus, which appeared as high-intensity signals on diffusion-weighted MRI (figure). No subdural abscesses or brain abscesses were present. We diagnosed thrombosis of the cavernous sinus and left superior ophthalmic vein.