Fatal Septic Internal Jugular Vein-Sigmoid Sinus Thrombosis Associated with a Malpositioned Central Venous Catheter
A 52-year-old woman presented with a severe bursting headache, vomiting, and a drowsy mentality. Brain computed tomography (CT) scan revealed subarachnoid hemorrhage in the basal cistern with a small amount of hematoma at the left Sylvian fissure (). We identified an aneurysmal rupture of the middle cerebral artery on the left side by cerebral catheter angiography () and performed aneurysmal clipping. Postoperative chest X-ray was normal except for malposition of the central venous catheter in the right internal jugular vein (). Unfortunately, we overlooked this important finding. Ten days later, the patient developed a fever, elevated white blood cell count to 227000, and elevated C-reactive protein to 33.6. The central venous catheter was removed, and antibiotics were administrated through a different intravenous route. Despite these managements, the patient was stupor the next day. We suspected vasospasm due to subarachnoid hemorrhage. Brain CT and CT angiography ruled out this possible diagnosis. Brain CT scan revealed cerebral infarction with hemorrhagic transformation in the right temporal lobe, and CT angiography did not identify vasospasm (). Retrospective analysis of the contrast-enhanced CT scan and CT angiography showed an "empty delta sign" and absence of venous flow within the right internal jugular vein-sigmoid sinus that was sufficient for diagnosis of sinus thrombosis (). Results of central venous catheter tip and blood culture was reported Staphylococcus epidermidis and Methicillin-resistant Staphylococcus aureus, respectively. Antibiotics were changed to vancomycin. We could not start systemic heparinization due to hemorrhagic transformation of the cerebral infarction in the right temporal lobe. We administrated mannitol and steroids to manage increased intracranial pressure; however, the patient died from severe pneumonia due to septic emboli after one week ().