However, Xiaohua, who just finished her twelfth birthday, was admitted to ICU for nearly a month because of an action and was pulled back from the gate of hell. What thrilling events did he experience?
Xiaohua is a smart and sensible student with excellent academic performance. Since this summer, her face has been covered with red pimples overnight, which makes the ignorant young flower miserable. As soon as he has nothing to do, he squeezes the pimples on his face in the mirror. However, he didn't get rid of the annoying acne on his face. On the contrary, the acne appeared elsewhere the next day, and the acne squeezed by him turned into a more red and swollen packet, which caught Xiaohua off guard. What surprised him even more, however, was that he squeezed into the acne at the root of his nose this time, which caused him to have fever, severe headache, edema of eyelid commissure and exophthalmos the next day.
The sudden change made Xiaohua's parents panic. After understanding the cause of the incident, they immediately sent Xiaohua to the emergency department of otolaryngology. The emergency doctor accepted Xiaohua, and after improving the collection of medical history, he considered that facial infection caused cavernous sinus thrombosis. The disease was dangerous, so he was transferred to the neurosurgical intensive care unit for further treatment. After receiving systematic treatment in the neurosurgical intensive care unit, Xiaohua turned the corner.
Cavernous sinus thrombosis is often caused by local infection in the head and face, mainly manifested as headache, cranial nerve dysfunction of cavernous sinus, fever, eyelid edema, conjunctival edema, exophthalmos and papillae edema caused by internal and external orbital venous reflux disorder. The common site is the cavernous sinus of the brain. The common cause is local infection of the head and face.
The cause of disease
1. Infectious etiology
Cavernous sinus thrombosis is often secondary to local infection, which is called inflammatory cavernous sinus thrombosis. Among them, acute inflammatory cavernous sinus thrombosis is mostly caused by head and face infection, while chronic inflammatory cavernous sinus thrombosis is mostly caused by sphenoid sinus, ethmoiditis and otitis media retrograde. Common local infection foci causing inflammatory cavernous sinus thrombosis are:
(1) Lesions of nasal cavity, oral cavity, eyes and face, such as furuncle and carbuncle.
(2) Lesions of sphenoid sinus and ethmoid sinus.
(3) Ear infection, such as otitis media or mastoiditis.
(4) Infection in other parts, such as osteomyelitis of maxilla, tonsillitis, abscess around tonsil, abscess in deep neck, etc.
2. Non-communicable etiology
Head injury, operation, chronic wasting disease, hypercoagulability and dural arteriovenous malformation near cavernous sinus or in front of brain.
3. Pathogens
The main pathogen causing cavernous sinus thrombosis is staphylococcus aureus, accounting for about 2/3 of all patients, followed by pneumococcus and streptococcus, followed by gram-negative bacilli, anaerobic bacteria and mold. With the wide application of antibiotics, the proportion of drug-resistant bacteria has increased year by year in recent years.
clinical picture
1. The main clinical manifestations of cavernous sinus thrombosis are the signs that cranial nerves (oculomotor nerve, trochlear nerve, abducens nerve and eye branch of trigeminal nerve) run in cavernous sinus, the signs of cranial nerves (optic nerve) adjacent to cavernous sinus, and the eye symptoms caused by venous reflux disorder inside and outside orbit.
2. Generally speaking, the first symptoms of cavernous sinus thrombosis are headache and facial pain, and the first signs are facial, eyelid and conjunctival edema, accompanied by high fever and exophthalmos; Then ophthalmoplegia occurs (abducens nerve first, oculomotor nerve and trochlear nerve second, trigeminal nerve last).
3. Paralysis of oculomotor nerve, trochlear nerve and abducens nerve can be manifested as limited eye movement in all directions, fixed eye, drooping eyelids, dilated pupils and disappearance of light and accommodation reflex.
4. Involvement of the ophthalmic branch of trigeminal nerve can lead to forehead and eyeball pain, decreased forehead sensation and disappearance of corneal reflex; When the second branch of trigeminal nerve is involved, there will be pain, numbness and hypoesthesia in cheeks and upper gums. Involvement of motor branches leads to masticatory paralysis, closed teeth, jaw and gum pain.
5. Less than 10% of patients may have optic nerve involvement, resulting in decreased vision or even blindness.
6. Obstruction of internal and external orbital venous reflux can cause eyelid and conjunctival edema, exophthalmos and papilla edema.
7. Bilateral cavernous sinuses are connected by circular sinuses. After a few days, bilateral exophthalmos, congestion and eyeball fixation may occur.
Image inspection
1. Head CT (Computed Tomography)
The diagnostic value of plain CT scan is limited, and even enhanced CT scan is difficult to diagnose cavernous sinus thrombosis. The suggestive manifestations are cavernous sinus swelling, irregular filling defect and ocular vein dilatation.
2. Head magnetic resonance imaging
It can directly display cerebral venous thrombosis and reflect its natural evolution process. It is an effective method to diagnose cerebral venous thrombosis, and it is also the first choice to diagnose cerebral venous sinus thrombosis, which plays an irreplaceable role in its follow-up. However, sometimes it is difficult to diagnose cavernous sinus thrombosis even if MRI and MRV are used together. In the early stage of cavernous sinus thrombosis, T 1WI was isointense and T2WI was hypointense. After a few days, there may be "bull's-eye" sign, central and other signals, and high signals around; In the second month, T 1WI, T2WI and other signals were high. Enhanced T 1WI showed cavernous sinus filling defect. MRI can also show signs of cerebral parenchymal vein occlusion, such as brain swelling (occupying effect, sulcus shallowing) with abnormal signal on T2WI, ventricular enlargement, intracerebral hematoma with peripheral edema, etc.
3. Head MRV (low field magnetic resonance cerebral venous sinus angiography)
The direct sign is the lack of high signal or low blood flow signal with fuzzy and irregular edge in the normal cavernous sinus; The indirect sign is the formation of collateral vein at the obstruction and the abnormal expansion of drainage vein through other ways.
4. Head CTV(CT venography)
The filling defect of sinus wall enhancement, abnormal venous collateral drainage and cerebellar tentorium enhancement.
5. venous phase 5. Digital subtraction angiography
Venous sinus filling defect, delayed emptying of contrast agent, venous collateral circulation.
6. Radionuclide imaging
The proximal nuclide concentration, delayed emptying and venous collateral of obstructive venous sinus can be seen.
7. Transcranial Doppler
It is very important to know the collateral circulation and recanalization ability of vein for evaluating prognosis and making treatment measures.
diagnose
The diagnosis of cavernous sinus thrombosis should be combined with the history, clinical manifestations, cerebrospinal fluid and imaging changes, especially the results of cerebral angiography.
1. Clinical manifestations
Typical cavernous sinus syndrome, as mentioned above.
2. Cerebrospinal fluid examination
The initial pressure can be normal or slightly higher; Clear or yellowish appearance; There are infectious factors and leukocytosis, and smear or culture can identify pathogenic bacteria.
3. EEG
Lack of specificity, about 70% showed slow wave.
4. Inspection fee
The number of white blood cells and neutrophils in blood routine increased, and the erythrocyte sedimentation rate accelerated.
complication
Inflammatory cavernous sinus thrombosis is prone to the following complications:
1. meningitis
It can be manifested as headache, vomiting, meningeal irritation and inflammatory changes in cerebrospinal fluid.
2. Brain abscess
It can be single or multiple, and the most common parts are frontal lobe, temporal lobe and cerebellum; It usually occurs in the recovery period, and it can also occur in 3 ~ 6 months after recovery. After the clinical symptoms are relieved, they often manifest as headache aggravation, nausea, vomiting, hemiplegia or epilepsy.
3. Extracerebral abscess
Such as pulmonary infarction, pneumonia, pulmonary abscess, empyema, renal abscess and orbital abscess.
4. Internal carotid artery disease
Such as internal carotid arteritis, internal carotid artery stenosis or obstruction, internal carotid aneurysm, internal carotid cavernous fistula, etc.
5. Pituitary lesions
Such as pituitary infection, necrosis, abscess and hypofunction.
differential diagnosis
1. Carotid cavernous sinus leakage
It is formed because the cavernous sinus segment of the internal carotid artery itself or its branches (meningeal pituitary trunk, inferior cavernous sinus artery and capsule artery) protrude into the cavernous sinus. Most of them have a history of head trauma, with typical symptoms and signs such as edema and congestion of commissural membrane, pulsating exophthalmos, intracranial vascular murmur, progressive vision loss at different stages after injury and so on. Combined with cerebral angiography, diagnosis can be made.
2. Cavernous sinus tumor
It mainly affects ⅲ ~ ⅵ cranial nerves. When tumors widely invade the cavernous sinus, orbit and middle cranial fossa, there may be anterior cavernous sinus syndrome (involving the ophthalmic branch of trigeminal nerve), middle cavernous sinus syndrome (involving the ophthalmic branch and maxillary branch of trigeminal nerve) and posterior cavernous sinus syndrome (involving all branches of trigeminal nerve), all of which may be accompanied by eye movement disorder (involving oculomotor nerve, trochlear nerve and abducent nerve jointly or separately), diplopia and ptosis. Meningioma, trigeminal neurilemmoma, invasive pituitary adenoma and chordoma are the main lesions, which can be differentiated by MRI plain scan and enhanced scan.
treat cordially
1. Improve the overall situation
Maintain the balance of water electrolysis, nutritional support, blood transfusion, and keep the respiratory tract unobstructed; Prevention of pneumonia, urinary tract infection and pressure ulcers; Analgesia and sedation; Use eye ointment and eye mask to protect your eyes.
2. Treatment of intracranial hypertension
Keep the respiratory tract and feces unobstructed, prevent high temperature, and appropriately limit the amount and speed of liquid; Mannitol, hormone, furosemide, glycerol fructose and other drugs used for dehydration, diuresis and relieving brain edema.
3. Surgical therapy
For patients with acute intracranial hypertension that is difficult to control with drugs, ventricular drainage, ventriculoperitoneal shunt, removal of intracerebral hematoma caused by venous congestion, decompressive craniectomy and venous bypass surgery can be considered.
4. Antiepileptic therapy
Once epilepsy is diagnosed, it should be treated immediately, and drugs with high curative effect, low toxicity and low price should be selected. The dressing should be changed gradually within 5 ~ 7 days to avoid causing status epilepticus.
5. Anti-inflammatory therapy
Inflammatory cavernous sinus thrombosis (suppurative cavernous sinus thrombosis or thrombotic cavernous sinus sinusitis) should be treated with antibiotics in an early, sufficient and full course of treatment, usually for 2-3 weeks, and then for 2-4 weeks as appropriate after local and systemic symptoms disappear.
6. Thrombolytic therapy
Commonly used drugs include urokinase (SK), streptokinase (UK), tissue plasminogen activator (t-PA), acetyl fiber plasminogen activator complex (APSAC), single-chain urokinase plasminogen activator (Scu-PA) and snake venom preparation. Thrombolytic methods include systemic intravenous thrombolysis, local intravenous thrombolysis and local intra-arterial thrombolysis.
7. Anticoagulation therapy
Commonly used drugs include heparin, heparin sodium, low molecular weight heparin, warfarin sodium, dicoumarin, sodium acetate nitrate coumarin, polysaccharide diester and so on. Anticoagulation contraindications include severe liver and kidney diseases, active tuberculosis, peptic ulcer, bleeding tendency, trauma, cerebral hemorrhage, subacute infective endocarditis and so on.
8. Interventional therapy
There are mainly femoral artery puncture, jugular vein puncture, carotid artery puncture and micro-ring assisted direct thrombolysis.
In life, we often hear that "the triangle of the face must not be touched", and it is often reported that squeezing blackheads and acne on the face leads to various infections and even brain abscesses. ...
So don't idle around, there is no protection!
Where is the facial triangle?
Danger triangle: an isosceles triangle area with the root of the human nasal bone as the vertex and the connecting line of the two corners as the bottom, including the upper and lower lips, nose, alar sides and other major facial organs.
Because this area is relatively convex, it is easy to cause skin inflammation, blackheads and acne. I can't help but want to scratch and dig. Don't squeeze the acne blackheads in the dangerous triangle of the face, otherwise it will cause serious complications.
The blood vessels in human face are like an extremely complicated overpass system, through which blood can reach anywhere.
There will be a venous valve consisting of two valves on the venous wall of other areas of the human body at regular intervals. When the blood flows to the heart, the two valves open and the blood passes smoothly. When blood flows out of the heart, the two valves overlap each other, closing the passage of blood circulation.
The venous valve is like a fan leaf, which ensures that blood can only flow back to the heart from the venous system and will not flow back in the venous system.
However, such venous valves do not appear in the blood vessels of the face. Because the muscles of the face are very rich, the veins are pushed by muscles, and the blood inside is likely to reflux.
Blood reflux is not a big problem, but if you happen to break the acne with unclean hands, external bacteria may run into the veins with the rupture of the acne. With the return of blood, these bacteria may be brought into larger veins and eventually merge into the cavernous sinus hidden behind the nose.
Cavernous sinus is an irregular cavity located behind our eyes and deep in the cranial cavity. Blood from the middle cerebral vein, the ophthalmic vein and the central retinal vein are collected here.
The oculomotor nerve, trochlear nerve, oculomotor nerve and maxillary nerve also pass through here, which is a well-deserved "danger zone".
Bacteria that have just "invaded" from acne wounds will breed great bacterial power in a blood-rich environment and enter the cavernous sinus, causing cavernous sinus sinusitis.
They will continue to spread to every corner of the brain, causing meningitis, encephalitis and even endangering the lives of patients: light people will feel dizzy, headache, neck pain and jet vomiting; In severe cases, you may have a high fever and then become dull; And if the bacteria are aggressive and the treatment is not timely, the patient will even die soon. Xiaohua is a real case at the beginning of the article.
If you really want to squeeze acne, please pay attention to these points:
1, make sure your hands are clean before squeezing acne;
2. Choose acne that has matured and suppurated;
3, after squeezing acne, we must also do a good job of cleaning and anti-inflammatory;
When the squeezed blood turns into blood, don't continue to squeeze. Excessive extrusion will cause excessive irritation to capillaries, which is not conducive to the recovery of acne. The safest way is to wait for the acne to subside by itself.
If you accidentally break the acne in the dangerous triangle and have the above symptoms, you must see a doctor immediately.