SHM Converge Scientific Abstract ePoster Gallery-From Suspected CSF Leak to Cavernous Sinus Thrombosis: An Evolving Presentation of Occult Oropharyngeal Squamous Cell Carcinoma

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An 86-year-old woman with a remote history of Hodgkin lymphoma in remission presented with three weeks of progressive headache, then diplopia and intermittent word-finding difficulty. Initial CT/CTA studies were unrevealing, but MRI showed left frontoparietal sulcal FLAIR hyperintensity and asymmetric pachymeningeal enhancement, raising concern for infection, inflammation, or a CSF leak. CT temporal bone suggested left tegmen thinning, and lumbar puncture was non-diagnostic. Repeat MRI again showed persistent pachymeningeal enhancement, mastoid effusion, and abnormal clival signal without evidence of intracranial hypotension. She was treated empirically with antibiotics for possible meningitis, meningoencephalitis, or skull-base osteomyelitis, and mastoid aspiration yielded sterile fluid. CT chest/abdomen/pelvis revealed multistation lymphadenopathy.<br /><br />While awaiting biopsy results, her condition worsened with new aphasia, left facial droop, and left orbital proptosis. CT head showed a new left frontal subdural hematoma. CTA/CTV then demonstrated superior ophthalmic vein thrombosis with cavernous sinus involvement. A supraclavicular lymph node biopsy confirmed metastatic squamous cell carcinoma, most consistent with an occult oropharyngeal primary.<br /><br />She was started on heparin infusion and high-dose IV methylprednisolone, but given the overall prognosis, the patient and family chose comfort-focused care. She was discharged home with hospice.<br /><br />This case highlights that cavernous sinus thrombosis and superior ophthalmic vein thrombosis are most often linked to infection, trauma, or inflammation, but can rarely be the first manifestation of malignancy. Progressive neurologic decline and imaging discordance should prompt reconsideration of the diagnosis even when CSF studies are negative. Malignancy, including head and neck squamous cell carcinoma, should remain in the differential when the clinical course does not fit an initial infectious or CSF-leak explanation.

Asset Subtitle

Zi Jun Deng

Meta Tag

Author List Kathleen Vogel, Linus Williams, Manal Makdhum, Michael Gelinas, Peter J. Mattingly, Zi Jun Deng

Category Clinical Vignettes

Concept Headache

Concept Diplopia

Concept Focal Neurologic Deficit

Concept Skull Base Process

Concept Intracranial Process

Distinguished Non-Finalist

Presenter Organization Lahey Hospital and Medical Center

Presenting Author Zi Jun Deng

Track Adult

Keywords

cavernous sinus thrombosis

superior ophthalmic vein thrombosis

metastatic squamous cell carcinoma

occult oropharyngeal primary

pachymeningeal enhancement

diplopia

headache

lymphadenopathy

subdural hematoma

skull-base osteomyelitis

Headache

Diplopia

Focal Neurologic Deficit

Skull Base Process

Intracranial Process