CAVERNOUS SINUS THROMBOSIS(CST)

FONG ZHAN YAN

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INTRODUCTION• The dural sinuses are grouped into the sagittal, lateral (including the

transverse, sigmoid, and petrosal sinuses), and cavernous sinuses.

• Because of its complex neurovascular anatomic relationship,

cavernous sinus thrombosis is the most important of any intracranial

septic thrombosis.

• Cavernous sinus thrombosis is usually a late complication of an

infection of the central face or paranasal sinuses.

Laupland KB. Vascular and parameningeal infections of the head and neck. Infect Dis Clin North Am. Jun 2007;21(2):577-90, viii. [Medline]

Septic?

Aseptic?

Anatomy of Cavernous Sinuses• Irregularly shaped

• The most centrally located of the dural

sinuses

• Lie on either side of the sella turcica.

• Lateral and superior to the sphenoid sinus

• Posterior to the optic chiasm.

Website, Medscape, Cavernous Sinus Thrombosis, Pathophysiology, Rahul Sharma, MD, MBA, FACEP

Venous Connection and Drainage• Receive venous blood from the facial veins, also sphenoid and

middle cerebral veins.

• Then drain into inferior petrosal sinuses internal jugular

veins & sigmoid sinuses via the superior petrosal sinuses.

• Contains no valves; blood can flow in any direction

• Infections of the face can spread easily by this route.

Website, Medscape, Cavernous Sinus Thrombosis, Pathophysiology, Rahul Sharma, MD, MBA, FACEP

Content of

Cavernous Sinuses:1. Internal carotid artery with its

surrounding sympathetic plexus

2. The third, fourth, and sixth cranial

nerves are attached to the lateral

wall of the sinus.

3. The ophthalmic and maxillary

divisions of the fifth cranial nerve

are embedded in the wall.III – OcculomotorIV – TrochlearV1 – Opthalmic branch of TrigeminalV2 – Maxillary branch of TrigeminalVI – Abducens

Causes and risk factors of CST:- Most cases occur when a bacterial infection in another part

of the skull or face spreads into the cavernous sinuses.

Staphylococcus aureus ~70% of all infections.

Streptococcus pneumonia

Fungi are less common - Aspergillus and Rhizopus species

- Patients with chronic sinusitis or diabetes mellitus may

be at a slightly higher risk

- Women who takes the oral contraceptive pill might be

more vulnerable to blood clots.

Staphylococcus aureus

Streptococcus pneumoniae

Website, Medscape, Cavernous Sinus Thrombosis, Pathophysiology, Rahul Sharma, MD, MBA, FACEPWebsite, National Health Service (UK), Cavernous Sinus Thrombosis, Introduction

HOW??

Extension of bacteria• Along the lateral sinus and petrosal

sinuses from middle ear infections

• Along the venous plexus surrounding the

internal carotid artery from the middle ear

• A dental infection from osteomyelitis

of the maxilla

Headache + Fever

Orbital pain + Periorbital Oedema + visual disturbance

Chemosis (swelling of the conjunctiva)

Mental status change

Focal cranial nerve abnormalities ** Exophthalmos

(bulging of the eye anteriorly out of the orbit)

Increased intraocular pressure

(fluid pressure inside the eye)

Decreased visual acuity

Hypoesthesia (reduced sense of touch or sensation)

Hyperesthesia

Meningism: nuchal rigidity (neck stiffness),

photophobia, headache

Functional and health consequences

Cranial nerve VI dysfunction

- Lateral gaze palsy

(The inability of an eye to turn outward – diplopia)

Cranial nerve III dysfunction

- Ptosis (drooping or falling of the upper or lower eyelid)

[CN III supply Levator palpebrae superioris]

- Mydriasis (dilation of the pupil)

[CN III supply sphincter pupillae]

Lateral gaze palsy

Patient trying to look left

Ptosis

Focal cranial nerve

abnormalities **

Functional and health consequences

Cranial nerve III, IV, VI dysfunction

- Complete Ophthalmoplegia

(paralysis of >1 extraocular muscles)

Cranial nerve V dysfunction

- Reduction of corneal reflex

- Periorbital sensory loss

Opthalmoplegia at left eye

Focal cranial nerve

abnormalities **

Functional and health consequences

Clinical relevance: case studyPatient:

60 years old Chinese male, with 15-year

history of Diabetes Mellitus presented to

his dentist with a 1-week history

toothache and subsequent painful right

cheek

Swollen, tender right cheek, pus @

third molar tooth

Extracted the tooth and treated with

antobiotics

Fever and extensive cheek

pain

Drainage of pus, found specific

bacteria

Further antibiotic treatment

Other complications

Symptoms and Signs

CT scanDiagnosis of CSTRevised treatment

and drainage

1. Patient came with swollen and tender right cheek, also with frank pusfrom upper right third molar tooth.

2. Tooth was extracted, then patient was treated with antibiotics(ticarcillin and gentamicin) based on culture growth of Pseudomonasaeruginosa.

3. On the 15th day, patient suffered from chills and fever, also extensivecheek pain.

4. Incision and drainage of pus were done on right buccal area andpreauricular region, after a radiological examination.

5. Culture of pus revealed the presence of P.aeruginosa and Enterococcus.6. Fever was subsided and leukocyte level was back to normal after

antibiotics treatment.7. (… renal complications, unstable blood pressure ICU for dialysis)

Clinical relevance: CASE study

Read more

8. Two days after discharge from ICU, rightperiorbital oedema and right lateral gaze wasfound.

9. Within 24 hours, right eye ptosis and chemosiswere seen; pupil was dilated and present withsluggish light reflex.

10. Then, complete paralysis of extraocularmuscles, retro-orbital pain was found.

11. CT scan revealed swelling at right cavernoussinus

12. Patient was diagnosed with septic CST13. Revised incision and drainage were done,

Heparin was added into the antibiotictreatment, there were reversal eye findingswithin 48 hours.

Clinical relevance: case study

In CT scan, CST can be

appreciated as increased

density

MRI is used to differentiate CST

from orbital cellulitis, as they have

similar clinical presentation.

MRV will show the absence of

venous flow in the affected

cavernous sinus.

Carotid Angiography, MRI and CT

scan can show narrowing and/or

obstruction of the carotid artery.

Imaging Studies

CT Scan

MANAGEMENT FOR CST

Early and aggressive antibiotic administration

Use of anticoagulation

Locally administered thrombolytics

Corticosteroids

Surgery on the cavernous sinus

Heparin

Prevents conversion of

fibrinogen to fibrin thus inhibit

further thrombogenesis.

Help to reduce inflammation

and edema

MANAGEMENT FOR CST

SUMMARY

• Cavernous Sinus contains CN 3,4,5,6 and internal carotid artery

• Cavernous Sinus Thrombosis is divided into septic and aseptic

• CST is mainly due to bacterial infections

• Thrombus is formed to prevent further spread of bacteria

• Patient with diabetes mellitus or women who take contraceptive pills

are at higher risk

• Consequences of it are mostly related to dysfunction of CN mentioned

above, including lateral palsy and ptosis

• Treatment of CST focuses on prescription of antibiotics, introduction

of anticoagulants and usage of corticosteroids

• Pus accumulated needs to be removed to avoid recurrence of CST

BOOKS:

Adams and Victor's Principles of Neurology, Ninth Edition, Chapter 34. Cerebrovascular Diseases

Copyright © 2009, 2005, 2001, 1997, 1993, 1989, 1985, 1981, 1977 by the McGraw-Hill Companies, Inc.

Authors: Allan H. Ropper, MD; Martin A. Samuels, MD, FAAN, MACP, DSc (Hon)

CURRENT Diagnosis & Treatment Emergency Medicine, Seventh Edition, Chapter 31. Eye Emergencies

Copyright © 2011 by the McGraw-Hill Companies, Inc.

Editors: C. Keith Stone, MD, Roger L. Humphries, MD

Principles of Critical Care, 3/e, Chapter 49. Endocarditis and Other Intravascular Infections

Copyright © 2005, 1998, 1992 by the McGraw-Hill Companies, Inc.

Editors: Jesse B. Hall, MD, Gregory A. Schmidt, MD, Lawrence D. H. Wood, MD, PhD

DeGowin's Diagnostic Examination, Ninth Edition, Chapter 7. The Head and Neck

Copyright © 2009, 2004 by the McGraw-Hill Companies, Inc.

Authors: Richard F. LeBlond, MD, MACP, Richard L. DeGowin, MD, FACP; Donald D. Brown, MD, FACP

REFERENCES

JOURNAL:

Aseptic Cavernous Sinus Thrombosis

Author: H. Coulter Todd, M.D., University of Oklahoma

CASE REPORT:

Cavernous sinus thrombosis following odontogenic and cervicofacial infection

October 1991, Volume 248, Issue 7, pp 422-424

Authors: M. Wen-Der Yun, C. F. Hwang, C. C. Lui

WEBSITES:

Medscape, Cavernous Sinus Thrombosis, Pathophysiology, Rahul Sharma, MD, MBA, FACEP

National Health Service (UK), Cavernous Sinus Thrombosis, Introduction

REFERENCES