Cavernous sinus thrombosis
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Transcript of Cavernous sinus thrombosis
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Dr. Parag MoonSenior resident
GMC, Kota
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Paired venous sinus, on either side of body of sphenoid.
2cm in length, height of 1cm
Traversed by numerous trabeculae, dividing it into a several caverns (spaces) hence cavernous.
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Relations: ◦ Medial – pituitary above, sphenoidal air cell below
◦ Lateral – temporal lobe, uncus
◦ Anterior - superior orbital fissure
◦ Posterior - petrous apex
◦ Superior – optic chiasm
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Tributaries:
– Superior and inferior opthalmic veins
– Sphenoparietal sinus
– Inferior cerebral veins
– Superficial middle cerebral veins
– Central vein of retina
Drainage:
– Superior petrosal sinus---> transverse sinus
– Inferior petrosal sinus --->internal jugular vein
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Communication:
– Intercavernous sinuses – communication between the 2
– Pterygoid plexus – via emissary veins passing through foramen ovale, emissary sphenoidalforamen and foramen lacerum.
– Pharyngeal plexus – via a vein passing through carotid canal.
– Facial vein – via superior opthalmic vein.
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Contents of cavernous sinus
- Internal Carotid artery with sympathetic plexus
- CN 3
- CN 4
- CN 5 (1st and 2nd divisions)
- CN 6
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Includes cases of phlebitis, thrombo-phlebitis and aseptic thrombosis
Septic type (most common) - coagulasepositive staphylococcus
Aseptic types may follow trauma, local stasis or a failing circulation.
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Septic CST
Infectious
Aseptic CST Trauma Post surgeryRhinoplastyBase of skullTooth extraction Hematologic MalignancyNasopharyngeal Ca. Dehydration
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More commonly seen with sphenoid and ethmoid and to a lesser degree with frontal sinusitis
Staphylococcus aureus -70% of all infections. Streptococcus pneumoniae, gram-negative bacilli, and anaerobes can also be seen.
Fungi are a less common pathogen and may include Aspergillus and Rhizopusspecies(more common in diabetics)
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No valves in dural sinuses, cerebral and emissary veins
Infection of upper lip, vestibule of nose and eyelids-> spread by way of angular, supraorbital, supratrochlear veins to ophthalmic veins=commonest route
Intranasal operation of septum, turbinates, ethmoid/sphenoid sinus infection->through ethmoidal veins
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Operation of tonsil, peritonsillar abcess, maxillary osteomyelitis/surgery, dental extraction->spread by pterygoid plexus or direct extension in internal jugular vein
Involvement of middle ear/mastoid -> retrograde spread through petrosal sinus to cavernous sinus
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Sources:
Nose – Paranasal 40%
Orbit- Face 35%
Mouth – Teeth 13%
Ear 9%
Other – tonsil, soft palate, pharynx, posterior portions of the superior and inferior alveolar arches 3%
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1. Sepsis
2. Venous obstruction
3. Involvement of cranial nerves
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Pyrexia
Rapid, weak, thready pulse
Chills and sweats
Delirium - meningitis supervenes terminally
Septic emboli to various other parts of body.
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Proptosis (first oedema & chemosis)
Oedema of eyelids and bridge of nose
Dilatation and tortuosity of retinal veins
Retinal hemorrhages
Involvement of the contralateral eye – (48 hours)
When pterygoid plexus is occluded along with sinus, - oedema of the pharynx or tonsil
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First CN involved is VI
Ptosis - paralysis of oculomotor nerve
Dilatation of pupil- third nerve and stimulation of sympathetic plexus
Decreased abduction (paralysis of abducensnerve)
Complete opthalmoplegia
Loss of vision
Retro-orbital pain and supra-orbital headache->V
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Strong clinical suspicion
1)Orbital venography
Not recommended
Difficult to puncture facial veins in odema
May help in dissemination of infection
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2) Contrast enhanced CT
Slice thickness 3mm or less
Shows enlargement and expansion of cavernous sinus cavity with flatening or convexity of lateral wall
Multiple or single filling defect with enhancing CS.
Exopthalmos, soft tissue edema
Dilation of superior ophthalmic vein
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3) MRI:
– A sensitive, noninvasive
Can be combined with venography to demonstrate lack of blood flow in the cavernous sinus
Show associated meningitis, involvement of pituitary gland
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4) CSF examination
Elevated protein
Normal sugar
Mild pleocytosis
5) Complete blood count
Elevated TLC
Leucocytosis
6) Blood culture
7) Local tissue culture
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Intracranial extension of infection-> meningitis, encephalitis, brain abcess, pituitary infection,epidural, subdural empyema
Cortical vein thrombosis->hemorrhagic infarction
Extension to other sinuses
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Orbital cellulitis–differentiated from CST by B/L involvement, papillodema, dilated pupil, decreased periocular sensation, abnormal spinal fluid in latter
Preseptal cellulitis- no proptosis
Orbital apex syndrome- more visual loss, opthalmoplegia, less proptosis, periorbitalodema
Sinusitis
Orbital malignancy
Facial Cellulitis
Glaucoma-angle closure
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Immediate empiric antibiotic coverage must include gram-positive, gram-negative and anaerobic bacteria.
Later treatment can be narrowed, adjusted to cultures and sensitivities
Third generation cephalosporin+vancomycinwith metronidazole
Duration- 3-4 weeks
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Used in setting of fungal sinusitis
More common in diabetics
Aspergillus more common
Parentral amphotericin B for 3 weeks followed by posaconazole(400mg BD) prophylaxis
Dose-0.5-1.5mg/kg/day(deoxycholate), 5-10mg/kg/day(liposomal)
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Intravenous heparin (maintaining the partial thromboplastin time or thrombin clot time at 1.5 to 2 times that of the control)->24,000-30,000 U/day.
Warfarin sodium (maintaining the prothrombin time at 1.3±1.5 times the control) -continued for 4 to 6 weeks to allow adequate collateral channels to develop
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Mortality was lower among patients who received heparin treatment, 14% vs. 36%
Early administration of heparin may serve to prevent spread of thrombosis to the other cavernous sinus as well as to the inferior and superior petrosal sinuses.
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Not influence mortality
May prevent residual cranial nerve dysfunction caused by inflammation.
Dexamethasone used most commonly
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Surgical drainage of affected sinuses
Endoscopic sinus surgery
Surgical debridement in fungal sinusitis
Surgical drainage of any collection
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100% mortality prior to antibiotics
30% mortality despite aggressive treatment
44% of survivors remain with chronic sequelae,
Roughly one sixth of patients are left with some degree of visual impairment
One half have cranial nerve deficits
Hypopituitarism- rare, can occur before or after 1 year.
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Septic cavernous sinus thrombosis-Neurology and Neurosciences;2014;4:117-118
Treatment of Cavernous Sinus Thrombosis; IMAJ 2002;4:468±469
Septic thrombosis of cavernous sinus-Arch Intern Med;2001;161:2671-2676