Right Infectious Cavernous Sinus Thrombosis Complicated by Multiple Cerebrovascular Events in the Right Hemisphere

Bacterial meningitis and infectious cavernous sinus thrombosis (CST) are both life-threatening central nervous system infections, often caused by sinusitis. While cerebrovascular complications are well-recognized in bacterial meningitis, their association with CST is rare. A 69-year-old man presented with a 19-day history of headache, followed by diplopia. On the day of admission, he developed left hemiparesis. On examination, he had mild right eye abduction impairment, dysarthria, mild left hemiparesis with left facial paralysis, and nuchal rigidity. At admission, brain computed tomography revealed sinusitis and a subarachnoid hemorrhage (SAH) in the right Sylvian fissure, while catheter angiography demonstrated right CST without cerebral aneurysm. Subsequent brain magnetic resonance imaging (MRI) revealed cerebral infarction in the right lateral striate artery territory. Cerebrospinal fluid (CSF) analysis showed elevated neutrophils, increased protein, and a decreased CSF/serum glucose ratio. The patient was treated with antimicrobial agents and heparin. Endoscopic sinus surgery was performed on day five after admission. Streptococcus intermedius (S. intermedius) was identified from sinus pus and blood cultures, leading to a diagnosis of bacterial meningitis. On day nine, a follow-up MRI was performed due to progressive left-sided weakness since day three. Contrast-enhanced imaging showed resolution of the cavernous sinus thrombus but revealed an extensive acute ischemic stroke in the right middle cerebral artery region. Consequently, heparin was discontinued, and cilostazol was initiated. Although his headache and diplopia improved, left-sided hemiplegia persisted. He was transferred to a rehabilitation hospital on day 32 after admission. In this case, the patient presented with right CST and bacterial meningitis, accompanied by SAH and acute ischemic stroke in the right cerebral hemisphere. CST and bacterial meningitis were likely secondary to sinusitis. The initial right temporal headache was attributed to inflammatory involvement of the internal carotid artery due to CST, which also contributed to cerebrovascular complications. The detected S. intermedius, a highly invasive pathogen, may have played a role in the extensive vascular complications. Though rare, CST requires careful monitoring for ipsilateral cerebrovascular complications.