Cavernous sinus thrombosis

Cavernous sinus thrombosis
Oblique section through the cavernous sinus.
Specialty	Neurology

Cavernous sinus thrombosis (CST) is the formation of a blood clot within the cavernous sinus, a cavity at the base of the brain which drains deoxygenated blood from the brain back to the heart. This is a rare disorder and can be of two types–septic cavernous thrombosis and aseptic cavernous thrombosis.^[1] The most common form is septic cavernous sinus thrombosis. The cause is usually from a spreading infection in the nose, sinuses, ears, or teeth. Staphylococcus aureus and Streptococcus are often the associated bacteria.^{[citation needed]}

Cavernous sinus thrombosis symptoms include: decrease or loss of vision,

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.^[3] Classic presentations are abrupt onset of unilateral periorbital

Staphylococcus aureus is the most common infectious microbe, found in 70% of the cases.[5] 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.^{[citation needed]}

Aseptic cavernous sinus thrombosis is much less common and is usually associated with other disorders including trauma, circulatory problems,

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. Cavernous sinus thrombosis is a clinical diagnosis with laboratory tests and imaging studies confirming the clinical impression.[8]

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.^{[citation needed]}

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 ophthalmic vein, and irregular filling defects within the cavernous sinus; however, findings may be normal early in the disease course. An 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.^[9]

Differential diagnosis

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

Treatment

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.^[10]

Antibiotics

Broad-spectrum intravenous antibiotics are used until a definite pathogen is found.^{[citation needed]}

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.^[11] 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.

People 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.^{[citation needed]}

All patients should be monitored for signs of complicated infection, continued sepsis, or septic emboli while antibiotic therapy is being administered.^{[citation needed]}

Heparin

Anticoagulation with heparin is controversial. Retrospective studies show conflicting data. This decision should be made with subspecialty consultation.^[12] One systematic review concluded that anticoagulation treatment appeared safe and was associated with a potentially important reduction in the risk of death or dependency.^[13]

Steroids

Steroid therapy is also controversial in many cases of CST.

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.^[citation needed]

References