View source for Cavernous sinus thrombosis

''The cavernous sinus is one of the several cerebral veins and cavernous sinus thrombosis is a specific type of [[cerebral venous thrombosis|cerebral venous (sinus) thrombosis]].  See that article for a discussion of the larger clinical entity.''

==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) 
*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)
**[[vision loss|Decreased vision]]
**Absent pupillary reflexes
**Decreased EOM secondary to CN III, IV, VI
***[[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 
*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==
*[[brain MRI|MRI]] with MR Venogram - study of choice 
*[[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 with a negative CT 
*Blood cultures

==Management==
*IV antibiotics: 
**3rd generation [[cephalosporin]] AND: 
**[[Nafcillin]] or [[vancomycin]]/[[linezolid]] if suspected MRSA and <br> 
**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
*[[focal neuro deficits|CNS deficit]]
*[[Adrenal Crisis|pituitary insufficiency]]

==See Also==
*[[Cerebral venous thrombosis]]

==References==
<references/>
[[Category:Ophthalmology]]
[[Category:Neurology]]
[[Category:Vascular]]