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. 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

Causes

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

Clinical Features

• Fevers, chills, N/V, headache
• Eye exam
  • infraorbital/periorbital cellulitis
  • Exophthalmos (uni/bl)
  • Decreased vision
  • Absent pupillary reflexes
  • Decreased EOM 2/2 CN III, IV, VI
    • CN VI typically affected 1st causing lateral gaze palsy
  • Decreased corneal sensation 2/2 CN V
• If infection spreads into CNS: AMS, 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

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

Treatment

• 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 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