Cavernous sinus thrombosis: Difference between revisions
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''The cavernous sinus is one of the several cerebral veins and cavernous sinus thrombosis is a specific type of [[cerebral venous thrombosis|cerebral venous (sinus) thrombosis]]. See that article for a discussion of the larger clinical entity.'' | ''The cavernous sinus is one of the several cerebral veins and cavernous sinus thrombosis is a specific type of [[cerebral venous thrombosis|cerebral venous (sinus) thrombosis]]. See that article for a discussion of the larger clinical entity.'' | ||
== Background | ==Background== | ||
*Severe infection involving complications of paranasal sinus and facial infections (e.g. manipulated midface abscesses, furuncles) | *Severe infection involving complications of paranasal sinus and facial infections (e.g. manipulated midface abscesses, furuncles) | ||
*Frequent extension of thrombosis to opposite sinus | *Frequent extension of thrombosis to opposite sinus | ||
*Low frequency, but high rate of morbidity/mortality | *Low frequency, but high rate of morbidity/mortality | ||
=== Causes | *Structures within the Cavernous Sinus | ||
**V1 and V2 | |||
**III, IV, VI | |||
**Internal Carotid Artery | |||
===Causes=== | |||
*[[Staph aureus]] | *[[Staph aureus]] | ||
*[[Strep pneumoniae]] | *[[Strep pneumoniae]] | ||
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*[[Fungi]] | *[[Fungi]] | ||
== Clinical Features | ==Clinical Features== | ||
*Fevers, chills, | *Fevers, chills, nausea and vomiting, headache | ||
*Eye exam | *Eye exam | ||
**infraorbital/periorbital cellulitis | **infraorbital/periorbital cellulitis | ||
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**Decreased vision | **Decreased vision | ||
**Absent pupillary reflexes | **Absent pupillary reflexes | ||
**Decreased EOM | **Decreased EOM secondary to CN III, IV, VI | ||
***CN VI typically affected 1st causing lateral gaze palsy | ***CN VI typically affected 1st causing lateral gaze palsy | ||
**Decreased corneal sensation | **Decreased corneal sensation secondary to CN V | ||
*If infection spreads into CNS: | *If infection spreads into CNS: altered mental status, lethargy, meningeal signs | ||
== Differential Diagnosis == | ==Differential Diagnosis== | ||
*Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus | *Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus | ||
*[[Cellulitis]] | *[[Cellulitis]] | ||
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*[[Sinusitis]] | *[[Sinusitis]] | ||
== | ==Evaluation== | ||
*MRI with MR Venogram - study of choice | *MRI with MR Venogram - study of choice | ||
*CT head/orbits with IV contrast | *CT head/orbits with IV contrast | ||
**CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT | **CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT | ||
*Blood | *Blood cultures | ||
== | ==Management== | ||
*IV antibiotics: | *IV antibiotics: | ||
**3rd generation cephalosporin and: | **3rd generation cephalosporin and: | ||
**Nafcillin or vancomycin/linezolid if suspected MRSA and <br> | **Nafcillin or vancomycin/linezolid if suspected MRSA and <br> | ||
**Anaerobic coverage if suspected dental source | **Anaerobic coverage if suspected dental source | ||
*Consider heparin if rapidly decompensating and CT | *Consider heparin if rapidly decompensating and CT negative for intracranial hemorrhage | ||
*Consider steroids to decrease inflammation in conjunction with antibiotics | *Consider steroids to decrease inflammation in conjunction with antibiotics | ||
*Surgical drainage of primary infection if possible | *Surgical drainage of primary infection if possible | ||
== Disposition | ==Disposition== | ||
*Consult ophthalmology, neurology, ID, surgery specialty (if drainage is needed) and admit ICU | *Consult ophthalmology, neurology, ID, surgery specialty (if drainage is needed) and admit ICU | ||
== Complications | ==Complications== | ||
*[[Meningitis]] | *[[Meningitis]] | ||
*Septic emboli | *Septic emboli | ||
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==References== | ==References== | ||
<references/> | |||
[[Category:Ophthalmology]] | [[Category:Ophthalmology]] | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:Vascular]] | [[Category:Vascular]] | ||
Revision as of 15:06, 7 December 2017
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
Clinical Features
- Fevers, chills, nausea and vomiting, headache
- Eye exam
- infraorbital/periorbital cellulitis
- Exophthalmos (uni/bl)
- Decreased vision
- Absent pupillary reflexes
- Decreased EOM secondary to CN III, IV, VI
- CN VI typically affected 1st causing lateral gaze palsy
- Decreased corneal sensation secondary to CN V
- If infection spreads into CNS: altered mental status, lethargy, meningeal signs
Differential Diagnosis
- Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus
- Cellulitis
- Periorbital vs Orbital Cellulitis
- Acute Angle-Closure Glaucoma
- Sinusitis
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:
- 3rd generation cephalosporin and:
- Nafcillin or vancomycin/linezolid if suspected MRSA and
- Anaerobic coverage if suspected dental source
- 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