Cavernous sinus thrombosis: Difference between revisions
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==Evaluation== | ==Evaluation== | ||
*[[brain MRI|MRI]] with MR Venogram - study of choice | *[[brain MRI|MRI]] with MR Venogram - study of choice | ||
*[[CT head]] Venogram acceptable choice if no MR available | *[[CT head]] Venogram acceptable choice if no MR available <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 if neg CT | **CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT | ||
*Blood cultures | *Blood cultures | ||
Revision as of 06:53, 29 November 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
- 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
- CN VI typically affected 1st causing lateral gaze palsy
- CN VI palsy and Horner Syndrome known as Parkinson sign[1]
- 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 [2]
- 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
See Also
References
- ↑ Harris FS and Rhoton, Jr. AL. Anatomy of the cavernous sinus: A microsurgical study. Journal of Neurosurgery. 1976; 45: 169-180.
- ↑ 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.