Two Cases of Internal Carotid Artery Stenosis Associated with Invasive Fungal Paranasal Sinusitis Detected by MRI/MRA

Abstract

Introduction: It has been reported that invasive fungal infections of the paranasal sinuses can lead to cerebrovascular disorder. Herein, we report two cases of invasive mycosis of the paranasal sinuses in which MRI/MRA revealed stenosis of the internal carotid artery.

Case 1: A 78-year-old male patient presenting with a 4-month history of visual field loss on the left side was diagnosed as having left optic perineuritis. CT revealed bilateral soft-tissue density within the sphenoethmoidal cells. MRI revealed that the lesion spread from the left orbital tip to the cavernous sinus. Bilateral endoscopic sinus surgery (ESS) was performed. We found fungal spores in both the sphenoethmoidal cells and in the defect in the left optic canal bone. Histopathology confirmed that the spores belonged to Aspergillus species, and the patient was started on treatment with oral voriconazole. MRI/MRA performed 1 month post-surgery showed stenosis of the left internal carotid artery siphon. No evidence of cerebral infarction was observed, presumably because of collateral cerebral blood flow. Until now, 4 years since the surgery, follow-up has revealed no evidence of recurrence of the lesion, although MRI/MRA reveals stenosis in the same region.

Cases 2: A 61-year-old male patient presenting with a 2-month history of visual disturbance on the left side was admitted to our ophthalmology department. CT showed a soft-tissue density within the left ethmoid and sphenoid sinuses. MRI revealed orbital and intracranial invasion. Biopsy was performed via endoscopic sinus surgery (ESS), and a final histopathological diagnosis of Mucor infection was made. The patient was started on treatment with liposomal amphotericin B. One month post-surgery, MRI/MRA showed stenosis of the left internal carotid artery siphon. The patient suffered multiple organ failure, and died 131 days after hospital admission.

Conclusion: We report two cases of internal carotid artery stenosis associated with invasive mycosis. Patients diagnosed with invasive mycosis should be considered to be at a high-risk for potential cerebral infarction and cerebral hemorrhage, and undergo cerebrovascular evaluation by MRI/MRA.