Cavernous sinus thrombosis: Difference between revisions

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== Background ==
''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==
[[File:Gray571.png|thumb|Oblique section through the cavernous sinus.]]
*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)  
*Frequently associated with
**Occular symptoms: pain, decreased vision, eye fixed in gaze, exophthalmos, eyelid edema
**Systemic infection: HA, N/V, fevers, chills
*CN III, IV, V (V1 and V2 branch), VI travel within cavernous sinus and are susceptible resulting in associated palsies<br>
*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


*Staph aureus, strep pneumoniae, gram neg bacilli, anaerobes, Fungi
===Causes===
*[[Staph aureus]]
*[[Strep pneumoniae]]
*[[Gram negative]] bacilli
*[[Anaerobes]]
*[[Fungi]]


== Clinical Features ==
==Clinical Features==
 
*[[Fevers]]/chills
*Fevers, chills, N/V, headache
*[[Nausea/vomiting]]
*Eye exam: Exophthalmos (uni/bl), decreased vision, absent pupillary reflexes, papilledema, decreased extraocular movement secondary to CN III, IV, VI, decreased corneal sensation secondary to CN V1
*[[Headache]]
**CN VI typically affected 1st causing lateral gaze palsy
*Eye exam
 
**infraorbital/periorbital [[cellulitis]]
*If infection spreads into CNS pt. w/ AMS, lethargy
**Exophthalmos (uni or bilateral)
 
**[[vision loss|Decreased vision]]
== Work Up  ==
**Absent pupillary reflexes
 
**Decreased EOM secondary to CN III, IV, VI
*CT Head/Orbits with contrast
***[[abducens nerve palsy|CN VI]] typically affected 1st causing lateral gaze palsy
**CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT
***CN VI palsy and [[Horner Syndrome]] known as Parkinson sign<ref>Harris FS and Rhoton, Jr. AL. Anatomy of the cavernous sinus: A microsurgical study. Journal of Neurosurgery. 1976; 45: 169-180.</ref>
*MRI with MR Venogram - study of choice
**Decreased corneal sensation secondary to CN V
*Blood Cx
*If infection spreads into CNS: altered mental status, lethargy, meningeal signs
 
== DDx  ==


==Differential Diagnosis==
*Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus  
*Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus  
*Cellulitis  
*[[Cellulitis]]
*Orbital/Periorbital infection
*[[Periorbital vs Orbital Cellulitis]]
*Acute Angle Closure Glaucoma  
*[[Acute Angle-Closure Glaucoma]]
*Sinusitis
*[[Sinusitis]]


== Treatment  ==
==Evaluation==
*[[brain MRI|MRI]] with MR Venogram - study of choice
*[[CT head]] Venogram acceptable choice if no MR available with 95% sensitivity <ref> Chiewvit P, Piyapittayanan S, Poungvarin N. Cerebral venous thrombosis: diagnosis dilemma. Neurol Int. 2011 Nov 29;3(3):e13. doi: 10.4081/ni.2011.e13. Epub 2011 Dec 15. PMID: 22368772; PMCID: PMC3286153. </ref>
**CT findings can be subtle and if clinical suspicion is high cannot rule out with a negative CT
*Blood cultures


*Immediately begin IV antibiotics:  
==Management==
**3rd generation Penicillin and
*IV antibiotics:  
**Nafcillin or Vancomycin/Linezolid if suspected MRSA and <br>  
**3rd generation [[cephalosporin]] AND:
**[[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 neg for intracranial hemorrhage  
*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, and ENT (or other appropriate surgery subspecialty)
*Consult ophthalmology, neurology, ID, surgery specialty (if drainage is needed) and admit ICU
*Admit to ICU
 
== Complications  ==
 
*Meningitis, septic emboli, remaining visual defects, CNS deficit, pituitary insufficiency
 
[[Category:Ophtho]], [[Category:Neuro]]


== Source  ==
==Complications==
*Harwood and Nuss
*[[Meningitis]]
*Tintinalli
*Septic emboli
*Emedicine
*Remaining visual defects
*[[focal neuro deficits|CNS deficit]]
*[[Adrenal Crisis|pituitary insufficiency]]


<br>
==See Also==
*[[Cerebral venous thrombosis]]


<br>
==References==
<references/>
[[Category:Ophthalmology]]
[[Category:Neurology]]
[[Category:Vascular]]

Latest revision as of 19:59, 7 December 2022

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

Oblique section through the cavernous sinus.
  • 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/vomiting
  • Headache
  • Eye exam
    • infraorbital/periorbital cellulitis
    • Exophthalmos (uni or bilateral)
    • Decreased vision
    • Absent pupillary reflexes
    • Decreased EOM secondary to CN III, IV, VI
    • 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 Venogram acceptable choice if no MR available with 95% sensitivity [2]
    • CT findings can be subtle and if clinical suspicion is high cannot rule out with a negative 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, and ENT (or other appropriate surgery subspecialty)
  • Admit to ICU

Complications

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.
  2. ↑ Chiewvit P, Piyapittayanan S, Poungvarin N. Cerebral venous thrombosis: diagnosis dilemma. Neurol Int. 2011 Nov 29;3(3):e13. doi: 10.4081/ni.2011.e13. Epub 2011 Dec 15. PMID: 22368772; PMCID: PMC3286153.
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