0:01

Diabetic patient, new onset of cranial nerve neuropathies

0:06

affecting the 3rd, 4th, and 6th cranial nerves.

0:10

Just given those that history,

0:11

we're going to be concerned about the cavernous sinus,

0:14

and this was on the left side.

0:16

Here we have the soft tissue window and the bone

0:18

window of this patient. On the soft tissue window,

0:21

we notice that there is this inflammatory process,

0:25

which appears to be eroding

0:27

the lateral aspect of the sphenoid sinus. Has a little bit

0:31

of hyperdensity and extends into the pterygoid air cell,

0:35

communication of the sphenoid sinus.

0:38

On CT bone windows, we have the pterygoid cell that's

0:44

communicating with the sphenoid sinusitis.

0:46

But unfortunately,

0:47

we also see erosion of this lateral border of the sphenoid

0:53

sinus, which communicates with the cavernous sinus.

0:56

So this is not showing hyperdense secretions like one would

1:00

of an allergic fungal sinusitis.

1:02

We're not seeing bony thickening of a chronic osteitis,

1:06

we're seeing an erosive acute process and we

1:09

worry about an invasive fungal sinusitis.

1:13

Let's look at the accompanying MRI scan.

1:17

On the MRI scan that was sent in from the outside,

1:21

we see the opacification of the sphenoid

1:24

air cell in the pterygoid region,

1:27

but we also see dark signal-intensity tissue which is

1:30

extending from the sphenoid sinus into the adjacent

1:36

intracranial compartment, and from there into the cavernous

1:40

sinus. Notice that this tissue is dark in signal intensity,

1:44

not bright in signal intensity,

1:45

making us even more concerned

1:47

about the potential for a fungal sinusitis.

1:50

This examination did not include post gadolinium-enhanced scan.

1:55

It did include a coronal scan where we can see

2:00

this low signal-intensity tissue in the inferior aspect of the

2:05

cavernous sinus expanding the cavernous

2:07

sinus on the left side.

2:09

The patient was transferred to Johns Hopkins

2:12

and we did a follow up study with MRI.

2:16

This is the inpatient Johns Hopkins study.

2:20

I'm going to set this up as a three-on-one.

2:24

And we look at the T2-weighted images, as

2:29

well as our post gadolinium enhanced scans

2:35

and we'll look at a CIS image.

2:37

So on the T2-weighted scan,

2:40

we again see low signal intensity soft tissue at the

2:44

orbital apex and extending to the cavernous sinus on

2:48

the left side. On the post gadolinium enhanced scan,

2:55

we see the asymmetric enhancement

2:58

of the anterior border of the cavernous

3:00

sinus, as well as at the superior orbital fissure

3:03

and orbital apex. And on the CIS image,

3:07

which is the highest resolution image,

3:10

you can see that dark signal intensity, which is extending

3:15

into the foramen rotundum, and from there extending to

3:19

the Meckel's cave region on the left side, and then the

3:26

enhancing soft tissue that's asymmetric on

3:28

the left side compared to the right side.

3:32

This was a patient who had invasive fungal sinusitis

3:36

affecting the left cavernous sinus and irritating the

3:39

associated cranial nerves to the extraocular muscles.

Case 41 - Invasive Fungal Sinusitis

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