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

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

• 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
  • 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 Venogram acceptable choice if no MR available with 95% sensitivity
  • CT findings can be subtle and if clinical suspicion is high cannot rule out with a negative 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, and ENT (or other appropriate surgery subspecialty)
• Admit to ICU

Complications

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

See Also

• Cerebral venous thrombosis