Cavernous sinus thrombosis
From WikEM
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.
Contents
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
Treatment
- 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 neg 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
