1. 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

2. Disclosures
None

3. 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.

4. 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.

5. 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)

6. 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)

7. 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

8. 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

9. 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)

10. 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

11. 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)

12. 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)

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

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

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

16. 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)

17. 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)

18. 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)

19. 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

20. 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)

21. 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)

22. 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)

23. 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

24. 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)

25. 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

26. 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

27. 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

28. 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)

29. 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)

30. 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).