Cavernous sinus thrombosis - Wikipedia, the free encyclopedia http://en.wikipedia.

org/wiki/Cavernous_sinus_thrombosis

From Wikipedia, the free encyclopedia

Cavernous sinus thrombosis (CST) is the formation of a Cavernous sinus thrombosis

blood clot within the cavernous sinus, a cavity at the base
Classification and external resources
of the brain which drains deoxygenated blood from the
brain back to the heart. The cause is usually from a
spreading infection in the sinuses, ears, or teeth.
Staphylococcus aureus and Streptococcus are often the
associated bacteria. Cavernous sinus thrombosis
symptoms include; decrease or loss of vision, drooping or
bulging eyes, headaches, and paralysis of the cranial
nerves which course through the cavernous sinus. This
infection is life-threatening and requires immediate
treatment, which usually includes antibiotics and
sometimes surgical drainage. Oblique section through the cavernous sinus.

ICD-9 325 (http://www.icd9data.com

/getICD9Code.ashx?icd9=325)

DiseasesDB 2184
(http://www.diseasesdatabase.com
1 Clinical features /ddb2184.htm)
2 Etiology eMedicine emerg/87 (http://www.emedicine.com
3 Diagnosis /emerg/topic87.htm) neuro/572
3.1 Differential diagnosis
(http://www.emedicine.com/neuro
3.2 Workup
/topic572.htm#)
3.2.1 Laboratory tests
3.2.2 Imaging studies MeSH D020226 (http://www.nlm.nih.gov
4 Treatment /cgi/mesh/2010/MB_cgi?field=uid&
4.1 Non-pharmacologic therapy term=D020226)
4.2 Acute general treatment
4.3 Long-term treatment
5 Key points
6 References

The clinical presentation of CST can be varied. Both acute, fulminant disease and indolent, subacute
presentations have been reported in the literature.

The most common signs of CST are related to anatomical structures affected within the cavernous sinus,
notably cranial nerves III-VI, as well as symptoms resulting from impaired venous drainage from the orbit
and eye.

Classic presentations are abrupt onset of unilateral periorbital edema, headache, photophobia, and bulging of
the eye (proptosis).

Other common signs and symptoms include:

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Ptosis, chemosis, cranial nelve palsies (III, IV, V, VI). Sixth nerve palsy is the most common. Sensory
deficits of the ophthalmic and maxillary branch of the fifth nerve are common. Periorbital sensory loss and
impaired corneal reflex may be noted. Papilledema, retinal hemorrhages, and decreased visual acuity and
blindness may occur from venous congestion within the retina. Fever, tachycardia and sepsis may be present.
Headache with nuchal rigidity may occur. Pupil may be dilated and sluggishly reactive. Infection can spread
to contralateral cavernous sinus within 24–48 hours of initial presentation.

CST most commonly results from contiguous spread of infection from the sinuses (sphenoid, ethmoid, or
frontal) or middle third of the face. Less common primary sites of infection include dental abscess, nares,
tonsils, soft palate, middle ear, or orbit (orbital cellulitis). The highly anastomotic and valveless venous
system of the paranasal sinuses allows retrograde spread of infection to the cavernous sinus via the superior
and inferior ophthalmic veins.

Staphylococcus aureus is the most common infectious microbe, found in 50% to 60% of the cases.
Streptococcus is the second leading cause. Gram-negative rods and anaerobes may also lead to cavernous
sinus thrombosis. Rarely, Aspergillus fumigatus and mucormycosis cause CST.

The diagnosis of cavernous sinus thrombosis is made clinically, with imaging studies to confirm the clinical
impression. Proptosis, ptosis, chemosis, and cranial nerve palsy beginning in one eye and progressing to the
other eye establish the diagnosis.

Differential diagnosis

Orbital cellulitis
Internal carotid artery aneurysm
Stroke
Migraine headache
Allergic blepharitis
Thyroid exophthalmos
Brain tumor
Meningitis
Mucormycosis
Trauma

Workup

Cavernous sinus thrombosis is a clinical diagnosis with laboratory tests and imaging studies confirming the
clinical impression.

Laboratory tests

CBC, ESR, blood cultures, and sinus cultures help establish and identify an infectious primary source.
Lumbar puncture is necessary to rule out meningitis.

Imaging studies

Sinus films are helpful in the diagnosis of sphenoid sinusitis. Opacification, sclerosis, and air-fluid levels are
typical findings. Contrast-enhanced CT scan may reveal underlying sinusitis, thickening of the superior

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ophthalmic vein, and irregular filling defects within the cavernous sinus; however, findings may be normal
early in the disease course.

A MRI using flow parameters and an MR venogram are more sensitive than a CT scan, and are the imaging
studies of choice to diagnose cavernous sinus thrombosis. Findings may include deformity of the internal
carotid artery within the cavernous sinus, and an obvious signal hyperintensity within thrombosed vascular
sinuses on all pulse sequences.

Cerebral angiography can be performed, but it is invasive and not very sensitive. Orbital venography is
difficult to perform, but it is excellent in diagnosing occlusion of the cavernous sinus.

According to the ICD-9M code, cavernous sinus thrombosis has a mortality rate of less than 20% in areas
with access to antibiotics. Before antibiotics were available, the mortality was 80-100%. Morbidity rates also
dropped from 70% to 22% due to earlier diagnosis and treatment.

Non-pharmacologic therapy

Recognizing the primary source of infection (i.e., facial cellulitis, middle ear, and sinus infections) and
treating the primary source expeditiously is the best way to prevent cavernous sinus thrombosis.

Acute general treatment

Broad-spectrum intravenous antibiotics are used until a definite pathogen is found.

1. Nafcillin 1.5 g IV q4h

2. Cefotaxime 1.5 to 2 g IV q4h
3. Metronidazole 15 mg/kg load followed by 7.5 mg/kg IV q6h

Vancomycin may be substituted for nafcillin if significant concern exists for infection by methicillin-resistant
Staphylococcus aureus or resistant Streptococcus pneumoniae.[1] Appropriate therapy should take into
account the primary source of infection as well as possible associated complications such as brain abscess,
meningitis, or subdural empyema.

Anticoagulation with heparin is controversial. Retrospective studies show conflicting data. This decision
should be made with subspecialty consultation.

Steroid therapy is also controversial and is not recommended by many sources.

Long-term treatment

Surgical drainage with sphenoidotomy is indicated if the primary site of infection is thought to be the
sphenoidal sinuses.

All patients with CST are usually treated with prolonged courses (3–4 weeks) of IV antibiotics. If there is
evidence of complications such as intracranial suppuration, 6–8 weeks of total therapy may be warranted.

All patients should be monitored for signs of complicated infection, continued sepsis, or septic emboli while
antibiotic therapy is being administered.

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Cavernous sinus thrombosis can be a life-threatening, rapidly progressive infectious disease with high
morbidity and mortality rates despite antibiotic use.

Complications of untreated CST include extension of thrombus to other dural venous sinuses, carotid
thrombosis with concomitant strokes, subdural empyema, brain abscess, or meningitis. Septic embolization
may also occur to the lungs, resulting in acute respiratory distress syndrome, pulmonary abscess, empyema,
and pneumothorax.

Complications in treated patients include oculomotor weakness, blindness, pituitary insufficiency, and
hemiparesis.

1. ^ W.J. Munckhof, A. Krishnan, P. Kruger, D. Looke (11 September 2007), Cavernous sinus
thrombosis and meningitis from community-acquired methicillin-resistant Staphylococcus aureus
infection (http://www3.interscience.wiley.com/journal/119419397/abstract?CRETRY=1&
SRETRY=0) , http://www3.interscience.wiley.com/journal/119419397/abstract?CRETRY=1&
SRETRY=0
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