Cavernous sinus thrombosis

The cavernous sinus is one of the several cerebral veins and cavernous sinus thrombosis is a specific type of cerebral venous (sinus) thrombosis. See that article for a discussion of the larger clinical entity.

Background
  • Severe infection involving complications of paranasal sinus and facial infections (e.g. manipulated midface abscesses, furuncles)
  • Frequent extension of thrombosis to opposite sinus
  • Low frequency, but high rate of morbidity/mortality
  • Structures within the Cavernous Sinus
    • V1 and V2
    • III, IV, VI
    • Internal Carotid Artery

Causes
  • Staph aureus
  • Strep pneumoniae
  • Gram negative bacilli
  • Anaerobes
  • Fungi

Clinical Features
  • Fevers/chills
  • Nausea/vomiting
  • Headache
  • Eye exam
    • infraorbital/periorbital cellulitis
    • Exophthalmos (uni or bilateral)
    • Decreased vision
    • Absent pupillary reflexes
    • Decreased EOM secondary to CN III, IV, VI
      • CN VI typically affected 1st causing lateral gaze palsy
      • CN VI palsy and Horner Syndrome known as Parkinson sign[1]
    • Decreased corneal sensation secondary to CN V
  • If infection spreads into CNS: altered mental status, lethargy, meningeal signs

Differential Diagnosis

Evaluation
  • MRI with MR Venogram - study of choice
  • CT head/orbits with IV contrast
    • CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT
  • Blood cultures

Management
  • IV antibiotics:
  • Consider heparin if rapidly decompensating and CT negative for intracranial hemorrhage
  • Consider steroids to decrease inflammation in conjunction with antibiotics
  • Surgical drainage of primary infection if possible

Disposition
  • Consult ophthalmology, neurology, ID, surgery specialty (if drainage is needed) and admit ICU

Complications
  • Meningitis
  • Septic emboli
  • Remaining visual defects
  • CNS deficit
  • pituitary insufficiency

See Also

References
  1. Harris FS and Rhoton, Jr. AL. Anatomy of the cavernous sinus: A microsurgical study. Journal of Neurosurgery. 1976; 45: 169-180.
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