Vascular Complications of Head & Neck Infections Emilio P. Supsupin Jr, MD Mary Guirguis, MD Brigid A. Bingham, MD Jeanie M. Choi, MD Marcelle Mallery, MD Eliana Bonfante, MD

Disclosures None

Purpose Vascular complications (VC) of head and neck infections (HNI) are a heterogeneous group of serious and potentially life-threatening conditions. Oftentimes the diagnosis is not suspected, and misdiagnosis or delayed diagnosis may lead to serious morbidity or mortality.

Approach/Methods A variety of clinical scenarios illustrate the seriousness of vascular complications arising from head and neck infections. These complications are depicted by multi-modality imaging.

Mastoiditis and dural venous sinus thrombosis Unenhanced head CT Temporal bone CT (bone window) Hyperattenuating clot in the right transverse/sigmoid sinuses (red arrows) Demineralization & subtle bony erosions in the sigmoid plate (blue arrow) Note bilateral mastoid effusions (circles)

Mastoiditis and dural venous sinus thrombosis Unenhanced T1-weighted MRI T2-weighted MRI Post-contrast T1 MRI Subacute clot in the right transverse and sigmoid sinuses (brackets) Note mastoid effusions (circles) Clot with abnormal enhancement in the right transverse & sigmoid sinuses (bracket)

MRV & DSA correlation MR venogram Catheter venography Catheter venogram corroborating the MR venogram findings with abrupt cutoff & large filling defect (brackets) in the right transverse sinus & lack of normal opacification of the sigmoid sinus and jugular bulb; note normal filling on the left Lack of flow-related signal in the right transverse/sigmoid Sinuses & normal flow-related signal on the left

Before and After Treatment Post-treatment DSA Residual stenosis in the right transvers sinus Before treatment Restoration of patency of the right transverse/sigmoid sinuses & right jugular bulb and internal jugular vein (arrows) following balloon angioplasty

Chronic skull base osteomyelitis with mastoiditis & dural venous sinus thrombosis Unenhanced T1-weighted MRI T2-weighted MRI T2-weighted MRI Loss of normal bone marrow signal in the left central skull base (circle) Note T1 hyperintensity of fatty marrow in the “normal” central skull base (arrows) Abnormal signal in the jugular fossa (circle) Left mastoid effusion (arrow)

Chronic skull base mastoiditis/osteomyelitis with dural venous sinus thrombosis Unenhanced T1-weighted MRI T2-weighted MRI T2-weighted MRI Erosive lesion in the left central skull base Subacute thrombosis of left sigmoid sinus with abnormal enhancement

Dural venous sinus thrombosis resulting from chronic skull base osteomyelitis/mastoiditis MR Venography Absent flow-related signal in left sigmoid sinus & Ieft internal jugular vein Normal flow-related signal in the right transverse and sigmoid sinuses and jugular bulb (blue arrows)

Dural venous sinus thrombosis from chronic skull base osteomyelitis/mastoiditis CT Angiography Absent flow in the left internal jugular vein (red arrows) Normal opacification of patent right internal jugular vein (yellow arrows)

Cavernous sinus thrombosis CT Angiogram Dilated superior ophthalmic vein (red arrows) Asymmetric distention of the left cavernous sinus (yellow arrow)

Cavernous sinus thrombosis CT Angiogram Dilated superior ophthalmic vein (red arrows) Asymmetric distention of the left cavernous sinus (yellow arrow)

Cavernous sinus thrombosis Contrast-enhanced CT Dilated superior ophthalmic vein (red arrows) Asymmetric distention of the left cavernous sinus (yellow arrow)

Cavernous sinus thrombosis Catheter angiogram (late venous phase) Initially suspected carotid cavernous sinus fistula not found on catheter angiogram Dilated superior ophthalmic vein (red arrow) Facial vein (yellow arrow)

Inflammatory changes in the left carotid space with arteritis and occlusion of the left internal carotid artery (ICA) and partial collapse of the left internal jugular vein (IJV) CT Angiogram Contrast in ICA lumen (red arrow) Normal right ICA (green arrow) Inflammatory changes in the left carotid space (circle) Normal right IJV (yellow arrow) Enlarged left ICA with enhancing walls (red arrow) Note inflammatory changes in the carotid space (circle) Partially collapsed left IJV (blue arrow)

Atypical skull base osteomyelitis (ASBO) T2-weighted MRI Unenhanced CT (bone window) Loss of normal marrow signal (circle) Mastoid effusion (blue bracket) Loss of normal flow voids in the occluded ICAs (yellow arrows) Normal flow-void in the patent basilar artery (red arrow) Bony erosions of the left central skull base (circle)

Massive bilateral hemispheric stroke resulting from atypical skull base osteomyelitis DWI ADC Diffusion restriction reflecting extensive acute hemispheric infarcts involving the bilateral MCA & bilateral ACA territories

Post septal cellulitis with cavernous thrombophlebitis Contrast-enhanced CT Extensive inflammatory changes in the orbital compartment (bracket) extending into the orbital apex (yellow arrows) Note asymmetric distension of the left cavernous sinus (red arrows)

Post septal cellulitis with superior ophthalmic vein thrombosis Contrast enhanced CT Asymmetrically enlarged & poorly opacified left superior ophthalmic vein (blue arrow), consistent with thrombosis Normal right superior ophthalmic vein (red arrow)

Post septal cellulitis extending into the orbital apex and cavernous sinuses with inflammatory/infectious arteritis involving the bilateral internal carotid arteries; focal meningitis Post contrast T1 MRI Contrast-enhanced MRI showing post septal inflammatory changes (brackets) extending into the orbital apex (yellow arrow) & cavernous sinuses (red circles) Note arterial wall enhancement in the cavernous carotid arteries (red arrows) with asymmetric narrowing of the left internal carotid artery lumen (blue arrows) Localized meningitis with dural enhancement (green arrows)

Orbital cellulitis with thrombosis of the left superior Ophthalmic vein & cavernous sinus thrombophlebitis Post contrast T1 MRI DWI Extensive inflammatory changes in the orbit (including adjacent sinuses) [circle] & extraorbital soft tissues [bracket] Normal, enhancing right superior ophthalmic vein (red arrow) There is lack of visualization of the thrombosed left superior ophthalmic vein. Increased DWI signal reflecting extension of inflammatory changes/infection in the bilateral cavernous sinuses

Panophthalmitis with ophthalmic periarteritis CTA & T2 weighted MRI depicting the left ophthalmic artery (red arrows) Note inflammatory changes of the orbit & retro-orbital space consistent with the clinical diagnosis of panophthalmitis (yellow circles) Retinal detachment/hemorrhage (blue arrow) Post contrast MRI showing enhancement surrounding the left ophthalmic artery consistent with ophthalmic periarteritis (red arrows)

Panophthalmitis with ophthalmic periarteritis DWI Coronal T1 Post-contrast Vigorous enhancement of the eyewall and retroorbital compartment (circles), consistent with the clinical diagnosis of panophthalmitis. Note also intense enhancement and enlargement of the left optic nerve sheath (arrow) Note circumferential diffusion restriction within or around the left orbital globe

Septic emboli DWI Same patient with leg infection – now with small foci of diffusion restriction in the right thalamus & right parietal cortex most concerning for septic emboli

Mycotic aneurysms/pseudoaneurysms Unenhanced CT showing hyperattenuating foci adjacent to the pons (red arrows) Note hypodensity in the right cerebellar vermis (circle) Restricted diffusion (acute infarcts) in the pons and cerebellar vermis on DWI

Mycotic aneurysms/pseudoaneurysms 3-D RSA (Rotational Subtraction Angiography) Post treatment catheter angiography Post treatment DSA showing coil masses in the basilar apex & right SCA 3D RSA depicting aneuryms/pseudoaneurysms of the basilar apex [red arrow] & right SCA (superior cerebellar artery) [yellow arrow] Post treatment DSA showing coil masses in the basilar apex (red arrow) and right SCA (yellow arrow)

Post meningitic vasculopathy/vasculitis T1 Post-contrast MRI FLAIR Diffuse pachymeningeal enhancement T2 changes in the central pons (circle) supratentorial white matter consistent with sequelae of prior Ischemic insults (arrows)

Post meningitic vasculopathy/vasculitis CT Angiogram Diffuse narrowing of the distal basilar artery including its cerebellar branches. In light of the patient’s clinical profile, this likely represents post meningitic vasculopathy/vasculitis. Similar changes are present in the anterior circulation (not shown).