Cavernous sinus thrombosis: Difference between revisions
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==Background== | ==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) | ||
*Frequent extension of thrombosis to opposite sinus | *Frequent extension of thrombosis to opposite sinus | ||
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==Clinical Features== | ==Clinical Features== | ||
*Fevers | *[[Fevers]]/chills | ||
*[[Nausea/vomiting]] | |||
*[[Headache]] | |||
*Eye exam | *Eye exam | ||
**infraorbital/periorbital cellulitis | **infraorbital/periorbital [[cellulitis]] | ||
**Exophthalmos (uni | **Exophthalmos (uni or bilateral) | ||
**Decreased vision | **[[vision loss|Decreased vision]] | ||
**Absent pupillary reflexes | **Absent pupillary reflexes | ||
**Decreased EOM secondary to CN III, IV, VI | **Decreased EOM secondary to CN III, IV, VI | ||
***CN VI typically affected 1st causing lateral gaze palsy | ***[[abducens nerve palsy|CN VI]] typically affected 1st causing lateral gaze palsy | ||
***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> | |||
**Decreased corneal sensation secondary to CN V | **Decreased corneal sensation secondary to CN V | ||
*If infection spreads into CNS: altered mental status, lethargy, meningeal signs | *If infection spreads into CNS: altered mental status, lethargy, meningeal signs | ||
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==Evaluation== | ==Evaluation== | ||
*MRI with MR Venogram - study of choice | *[[brain MRI|MRI]] with MR Venogram - study of choice | ||
*CT head/ | *[[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 | **CT findings can be subtle and if clinical suspicion is high cannot rule out with a negative CT | ||
*Blood cultures | *Blood cultures | ||
== | ==Management== | ||
*IV antibiotics: | *IV antibiotics: | ||
**3rd generation cephalosporin | **3rd generation [[cephalosporin]] AND: | ||
**Nafcillin or vancomycin/linezolid if suspected MRSA and <br> | **[[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 negative 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, surgery | *Consult ophthalmology, neurology, ID, and ENT (or other appropriate surgery subspecialty) | ||
*Admit to ICU | |||
==Complications== | ==Complications== | ||
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*Septic emboli | *Septic emboli | ||
*Remaining visual defects | *Remaining visual defects | ||
*CNS deficit | *[[focal neuro deficits|CNS deficit]] | ||
*[[Adrenal Crisis|pituitary insufficiency]] | *[[Adrenal Crisis|pituitary insufficiency]] | ||
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
- 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 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:
- 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
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.