PMC8247725_01
Sinus computed tomography (CT) scan at the clinical onset. Axial (a) and sagittal (b) CT scan examination with soft-tissue algorithm showing right maxillary invasive sinusitis. Note focal sinus medial wall discontinuities (red arrows in a) and partial obliteration of normal fat planes in the pterygomaxillary fissure (arrowheads in a and b).
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Sinus magnetic resonance imaging. Axial (a and b) and coronal (c and d) fast spin echo T2-weighted images show low signal effusion in the left maxillary sinus, at the level of ethmoidal air cells and sphenoid sinus, predominantly on the right (arrows).
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No acute cerebral involvement was observed [Figure 2].
Brain magnetic resonance imaging examination at neurological onset. Coronal contrast-enhanced fat saturation T1-weighted (a and b), coronal basal fat saturation T1-weighted (c), axial fluid-attenuated inversion recovery (d), axial diffusion-weighted (e) images. (a and b): Bilateral cavernous sinus thrombosis (arrows), bilateral V3 swelling without contrast enhancement (arrowheads); (c): bilateral V2 swelling (arrowheads); (d and e): high signal bilateral pontine foci, due to perineural diffusion. Note diffusion restriction at intracisternal tract of right trigeminal nerve (white arrow).
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MRI [Figure 3]. Main significant MRI findings were bilateral cavernous sinuses thrombosis, more evident on the left side, and slight swelling of the V2-V3 nerve roots on both sides without evidence of contrast enhancement.
Follow-up brain magnetic resonance imaging examination Axial fluid-attenuated inversion recovery (a), axial diffusion-weighted (b), axial contrast-enhanced fat saturation T1-weighted (c and d) images. Volume rendering technique (VRT) time-of-flight magnetic resonance angiography. (a and b) Bilateral acute frontoparietal watershed infarction; (c): left internal carotid artery (ICA) wall enhancement, due to mucormycosis vasculitis (arrow); (d): left endophthalmitis with crystalline lens dislocation (arrowhead) VRT angiography well depicts left ICA thrombosis.
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Last follow-up MRI examination performed a week later, before the exitus, also demonstrated left endophthalmitis with c rystalline lens dislocation and significant extension of parenchymal ischemic foci [Figure 4].