Cavernous sinus thrombosis

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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 (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

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

See Also

References