Cavernous sinus thrombosis: Difference between revisions

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''The cavernous sinus is one of the several cerebral veins and cavernous sinus thrombosis is a specific type of [[cerebral venous (sinus) thrombosis|cerebral venous thrombosis]].  See that article for a discussion of the larger clinical entity.''
''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 ==
==Background==
*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  
*Low frequency, but high rate of morbidity/mortality
*Low frequency, but high rate of morbidity/mortality


== Causes  ==
*Structures within the Cavernous Sinus
*Staph aureus, strep pneumoniae, gram neg bacilli, anaerobes, fungi
**V1 and V2
**III, IV, VI
**Internal Carotid Artery


== Clinical Features ==
===Causes===
*Fevers, chills, N/V, headache
*[[Staph aureus]]
*[[Strep pneumoniae]]
*[[Gram negative]] bacilli
*[[Anaerobes]]
*[[Fungi]]
 
==Clinical Features==
*[[Fevers]]/chills
*[[Nausea/vomiting]]
*[[Headache]]
*Eye exam
*Eye exam
**infraorbital/periorbital cellulitis
**infraorbital/periorbital [[cellulitis]]
**Exophthalmos (uni/bl)
**Exophthalmos (uni or bilateral)
**Decreased vision
**[[vision loss|Decreased vision]]
**Absent pupillary reflexes
**Absent pupillary reflexes
**Decreased EOM 2/2 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 2/2 CN V  
***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>
*If infection spreads into CNS: AMS, lethargy, meningeal signs
**Decreased corneal sensation secondary to CN V  
 
*If infection spreads into CNS: altered mental status, lethargy, meningeal signs
== Work Up  ==
*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 Cx
 
== DDx  ==


==Differential Diagnosis==
*Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus  
*Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus  
*[[Cellulitis]]
*[[Cellulitis]]
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*[[Sinusitis]]
*[[Sinusitis]]


== Treatment  ==
==Evaluation==
*[[brain MRI|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:  
*IV antibiotics:  
**3rd generation cephalosporin and:  
**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 neg 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 specialty (if drainage is needed) and admit ICU
*Consult ophthalmology, neurology, ID, surgery specialty (if drainage is needed) and admit ICU


== Complications ==
==Complications==
 
*[[Meningitis]]
*[[Meningitis]], septic emboli, remaining visual defects, CNS deficit, [[Adrenal Crisis|pituitary insufficiency]]
*Septic emboli
*Remaining visual defects
*[[focal neuro deficits|CNS deficit]]
*[[Adrenal Crisis|pituitary insufficiency]]


[[Category:Ophtho]], [[Category:Neuro]]
==See Also==
*[[Cerebral venous thrombosis]]


== Source  ==
==References==
*Harwood and Nuss
<references/>
*Tintinalli
[[Category:Ophthalmology]]
*Emedicine
[[Category:Neurology]]
[[Category:Vascular]]

Revision as of 17:06, 13 January 2021

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
    • Decreased corneal sensation secondary to CN V
  • If infection spreads into CNS: altered mental status, lethargy, meningeal signs

Differential Diagnosis

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:
  • 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

See Also

References

  1. Harris FS and Rhoton, Jr. AL. Anatomy of the cavernous sinus: A microsurgical study. Journal of Neurosurgery. 1976; 45: 169-180.