Cavernous sinus thrombosis

Revision as of 17:40, 13 December 2012 by Jswartz (talk | contribs)

Background

  • Severe infection involving complications of paranasal sinus and facial infections (e.g. manipulated midface abscesses, furuncles)
  • Frequently associated with
    • Occular symptoms: pain, decreased vision, eye fixed in gaze, exophthalmos, eyelid edema
    • Systemic infection: HA, N/V, fevers, chills
  • CN III, IV, V (V1 and V2 branch), VI travel within cavernous sinus and are susceptible resulting in associated palsies
  • Frequent extension of thrombosis to opposite sinus
  • Low frequency, but high rate of morbidity/mortality

Causes

  • Staph aureus, strep pneumoniae, gram neg bacilli, anaerobes, Fungi

Clinical Features

  • Fevers, chills, N/V, headache
  • Eye exam: Exophthalmos (uni/bl), decreased vision, absent pupillary reflexes, papilledema, decreased extraocular movement secondary to CN III, IV, VI, decreased corneal sensation secondary to CN V1
    • CN VI typically affected 1st causing lateral gaze palsy
  • If infection spreads into CNS pt. w/ AMS, lethargy

Work Up

  • CT Head/Orbits with contrast
    • CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT
  • MRI with MR Venogram - study of choice
  • Blood Cx

DDx

  • Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus
  • Cellulitis
  • Orbital/Periorbital infection
  • Acute Angle Closure Glaucoma
  • Sinusitis

Treatment

  • Immediately begin IV antibiotics:
    • 3rd generation Penicillin and
    • Nafcillin or Vancomycin/Linezolid if suspected MRSA and
    • Anaerobic coverage if suspected dental source
  • Consider heparin if rapidly decompensating and CT neg 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,

Source

  • Harwood and Nuss
  • Tintinalli
  • Emedicine