Case Presentation: An 86-year-old woman with a remote history of Hodgkin lymphoma presented with three weeks of headache and one week of intermittent diplopia and fluctuating word-finding difficulty. Head CT and CTA were unremarkable. Brain MRI showed left frontoparietal sulcal FLAIR hyperintensity with asymmetric pachymeningeal enhancement concerning for infection or inflammation, but lumbar puncture was non-diagnostic. Temporal-bone CT demonstrated left tegmen thinning with possible dehiscence, raising concern for a CSF leak and prompting transfer to a tertiary care facility for further evaluation. At the tertiary hospital, a repeat brain MRI demonstrated persistent left sided pachymeningeal enhancement, a new left mastoid effusion, and an abnormal appearing clivus without features of intracranial hypotension. Findings were consistent with infectious or neoplastic etiologies rather than CSF leak. Empiric antibiotics were started for possible meningitis, meningeal encephalitis or early skull-base osteomyelitis secondary to left-sided otitis media, but aspiration of the effusion yielded sterile serous fluid. Subsequent CT chest/abdomen/pelvis showed multistation lymphadenopathy, shifting suspicion towards malignancy. While awaiting biopsy, she developed new aphasia and left facial droop. CT showed a new left frontal subdural hematoma. Interval scans demonstrated radiographical left orbital proptosis followed by marked clinical proptosis the next day. CTA/CTV demonstrated left superior ophthalmic vein thrombosis with cavernous sinus involvement. Heparin infusion was started for thrombus stabilization and high-dose intravenous methylprednisolone was administered due to presumed neoplastic inflammatory involvement. Pathology from a left supraclavicular node biopsy ultimately revealed metastatic squamous cell carcinoma suggestive of oropharyngeal origin. After multidisciplinary discussion, the patient and family elected for comfort-focused care, and she was discharged home under hospice support.
Discussion: This case illustrates a rare example of ophthalmic vein thrombosis and cavernous sinus thrombosis as the initial presentation of an occult head and neck malignancy. Most CST/SOVT cases arise from infection, inflammation, or trauma rather than underlying cancer (Soutoudeh et al 2019, Housley et al 2024). Case reports in literature note malignancy-associated CST commonly occurs late in known disease (Sultania et al 2023) or as part of widespread thrombosis (Cameron et al 2024). CST/SOVT emerging as index manifestation of previously unrecognized occult head and neck cancer is uncommon and may be under-reported. This case highlights the diagnostic challenge posed by occult metastatic intracranial and skull-base adjacent malignancies, which can mimic a variety of primary neurologic conditions. Retrospective review of the clinical course underscores the limitation of the initial lumbar puncture cytology due to low diagnostic yield. Negative results should not be considered sufficient to exclude malignancy in a hospitalized patient with unexplained neurologic symptoms. Non-improvement, worsening deficits, or discordant imaging should prompt reconsideration of malignancy.
Conclusions: This case highlights the diagnostic challenge posed by an unusual presentation of ophthalmic vein thrombosis/cavernous sinus thrombosis as the index finding of an occult head/neck malignancy.