Images in...

Images in paediatrics: Sinovenous thrombosis due to mastoiditis

Sashank Prasad¹, Grant T Liu¹, Nicholas S Abend², Rebecca N Ichord²

¹ Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
² Department of Pediatrics, Division of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA

Correspondence to:
sashank.prasad{at}uphs.upenn.edu

A 9-year-old child presented with a 4-week history of headache, diplopia and mastoid pain. She was diagnosed with mastoiditis, received intravenous antibiotics and underwent mastoidectomy. Headache and diplopia persisted and the neurology service was consulted. Examination revealed right sixth nerve palsy and bilateral papilloedema. MRI demonstrated mastoid opacification and inflammation, and ipsilateral jugular and sigmoid venous sinus thrombosis (fig 1). The patient received low-molecular-weight heparin and acetazolamide, with prompt resolution of headache, diplopia and papilloedema.

View this figure (74K): in this window | in a new window | PowerPoint for Teaching   Figure 1 (A, B) MR venography demonstrates signal void in the right sigmoid sinus and jugular vein (arrow). (C) T1 weighted MRI demonstrates opacification of the right mastoid (arrow) and the venous hyperintensity (dotted arrow) indicates that absent flow-related signal on venography is due to acute clot, not sinus hypoplasia.

 

Sinovenous thrombosis (SVT) is a known complication of acute mastoiditis,¹ and although the incidence of SVT has declined in the antibiotic era, it remains an important diagnostic consideration.^2–4 In most cases, treatment of SVT includes aggressive hydration and anticoagulation, which has been associated with improved cognitive outcome and a trend to lower mortality³ without an increase in intracranial haemorrhage.^{3 4} The clinical improvement may occur long before the thrombosis improves on imaging and may be related to improved microcirculatory venous drainage. Delay in diagnosis and initiation of treatment with anticoagulation may increase morbidity, including permanent visual deficits.

This article has been adapted from Prasad Sashank, Liu Grant T, Abend Nicholas S, Ichord Rebecca N. Images in paediatrics: Sinovenous thrombosis due to mastoiditis Archives of Disease in Childhood 2007;92:749

Competing interests: None.

1. Tomkinson, A, Mills, RG, & Cantrell, PJ. The pathophysiology of otitic hydrocephalus. J Laryngol Otol 1997;111(8):757–9.[Medline]
2. Go, C, Bernstein, JM, de Long, AL, et al. Intracranial complications of acute mastoiditis. Int J Pediatr Otorhinolaryngol 2000;52(2):143–8.[CrossRef][Medline]
3. DeVeber, G, Andrew, M, Adams, C, et al. Cerebral sinovenous thrombosis in children. N Engl J Med 2001;345(6):417–23.[Abstract/Free Full Text]
4. Sebire, G, Tabarki, B, Saunders, DE, et al. Cerebral venous sinus thrombosis in children: risk factors, presentation, diagnosis, and outcome. Brain 2005;128:477–89.[Abstract/Free Full Text]

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