Cavernous sinus thrombosis: Difference between revisions
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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 | ||
**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/orbits with IV contrast | *[[CT head]]/orbits with IV contrast | ||
**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 | ||
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==Management== | ==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 | ||
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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]] | ||
Revision as of 00:34, 2 October 2019
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
- 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
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