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Cavernous Sinus Thrombosis


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An assignment for IMU Semester One BDS programme. :)

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Cavernous Sinus Thrombosis

  2. 2. 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?
  3. 3. 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
  4. 4. 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
  5. 5. 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 – Occulomotor IV – Trochlear V1 – Opthalmic branch of Trigeminal V2 – Maxillary branch of Trigeminal VI – Abducens
  6. 6. 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, FACEP Website, National Health Service (UK), Cavernous Sinus Thrombosis, Introduction
  7. 7. HOW??
  8. 8. 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
  9. 9. Functional and health consequences  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
  10. 10. Functional and health consequences Cranial nerve VI dysfunction Lateral gaze palsy Patient trying to look left - 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] Ptosis Focal cranial nerve abnormalities **
  11. 11. 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 **
  12. 12. Clinical relevance: case study Patient: 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 Diagnosis of CST CT scan Revised treatment and drainage
  13. 13. Clinical relevance: CASE study 1. Patient came with swollen and tender right cheek, also with frank pus from upper right third molar tooth. 2. Tooth was extracted, then patient was treated with antibiotics (ticarcillin and gentamicin) based on culture growth of Pseudomonas aeruginosa. 3. On the 15th day, patient suffered from chills and fever, also extensive cheek pain. 4. Incision and drainage of pus were done on right buccal area and preauricular 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) Read more 
  14. 14. Clinical relevance: case study 8. Two days after discharge from ICU, right periorbital oedema and right lateral gaze was found. 9. Within 24 hours, right eye ptosis and chemosis were seen; pupil was dilated and present with sluggish light reflex. 10. Then, complete paralysis of extraocular muscles, retro-orbital pain was found. 11. CT scan revealed swelling at right cavernous sinus 12. Patient was diagnosed with septic CST 13. Revised incision and drainage were done, Heparin was added into the antibiotic treatment, there were reversal eye findings within 48 hours.
  15. 15. Imaging Studies 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. CT Scan
  16. 16. 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
  18. 18. 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
  19. 19. REFERENCES 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
  20. 20. 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