II. Pathophysiology

  1. Most common infection of dural sinus thrombosis
  2. Sources
    1. Mid-face infections near the eyes and nose (e.g. nasal Furuncle)
    2. Sphenoid Sinus or Ethmoid Sinus infection
    3. Dental Infection (uncommon)

III. Symptoms

  1. Initial (first 1-2 days)
    1. Headache (most common
      1. Sharp pain increasing in severity becoming refractory and interferes with sleep
      2. Unilateral frontal and retroorbital Headache (Trigeminal Nerve ophthalmic and Maxillary branches)
  2. Next
    1. Fever
    2. Eye swelling
    3. Chemosis
    4. Diplopia
    5. Altered Level of Consciousness

IV. Signs

  1. Classic, severe presentation
    1. Fever
    2. Bilateral Ptosis
    3. Proptosis
    4. Ocular muscle paralysis
  2. Eye findings
    1. Lateral gaze palsy (CN 6)
    2. Eye looks down and laterally (CN 3)
    3. Eyelid Ptosis
    4. Mydriasis
    5. Fundus Exam (abnormal in two thirds of patients)
      1. Papilledema
      2. Dilated tortuous Retinal veins
  3. Other neurologic findings
    1. Trigeminal Nerve (CN 5) deficits

V. Imaging

  1. Orbital CT with contrast
  2. MRI with gadolinium enhancement

VI. Management

  1. Antibiotics
    1. MRSA coverage and initial empiric management
      1. Vancomycin 15-20 mg/kg (up to 2 g) IV every 8-12 hours AND
      2. Ceftriaxone 2 g IV every 12 hours or Cefepime 2 g IV every 8-12 hours
      3. Add Metronidazole 500 mg every 8 hours for Dental Infection (or higher dose for Brain Abscess)
    2. MSSA coverage (if confirmed by culture)
      1. Nafcillin or Oxacillin 2 g IV every 4 hours
  2. Anticoagulation
    1. Heparin (still recommended as of 2016)
  3. Glucocorticoids
    1. Dexamethasone 10 mg IV every 6 hours
  4. Surgery
    1. Emergent surgical drainage of Sphenoid Sinus should be considered

VII. References

  1. Southwick (2016) Septic Dural Sinus Thrombosis, UpToDate, accessed online 4/8/2016
  2. (2016) Sanford Guide, accessed on IPad App 4/8/2016

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Ontology: Cavernous Sinus Thrombosis (C0238454)

Definition (MSH) Formation or presence of a blood clot (THROMBUS) in the CAVERNOUS SINUS of the brain. Infections of the paranasal sinuses and adjacent structures, CRANIOCEREBRAL TRAUMA, and THROMBOPHILIA are associated conditions. Clinical manifestations include dysfunction of cranial nerves III, IV, V, and VI, marked periorbital swelling, chemosis, fever, and visual loss. (From Adams et al., Principles of Neurology, 6th ed, p711)
Concepts Disease or Syndrome (T047)
MSH D020226
SnomedCT 89980009
English Cavernous Sinus Thrombosis, Cerebr ven thromb of caver sin, thrombosis of cavernous sinus, thrombosis of cavernous sinus (diagnosis), Cavernous sinus thrombosis, Cavernous Sinus Thromboses, Sinus Thromboses, Cavernous, Sinus Thrombosis, Cavernous, Thromboses, Cavernous Sinus, Thrombosis, Cavernous Sinus, Cavernous Sinus Thrombosis [Disease/Finding], sinus cavernous thrombosis, cavernous sinus thrombosis, thrombosis cavernous sinus, Thrombosis of cavernous venous sinus, Cerebral venous thrombosis of cavernous sinus, Thrombosis of cavernous venous sinus (disorder), cavernous; thrombosis, thrombosis; cavernous
Italian Trombosi di seno cavernoso, Trombosi del seno cavernoso
Swedish Sinus cavernosustrombos
Japanese カイメンジョウミャクドウケッセンショウ, 血栓-海綿静脈洞, 敗血症性静脈炎-海綿静脈洞, 海綿静脈洞敗血症性静脈炎, 血栓症-海綿静脈洞, 海綿静脈洞血栓, 海綿静脈洞血栓症
Czech sinus cavernosus - trombóza, Trombóza kavernózního splavu
Finnish Lokeroveriviemärin tromboosi
Russian FLEBIT SEPTICHESKII KAVERNOZNOGO SINUSA, KAVERNOZNOGO SINUSA TROMBOZ, KAVERNOZNOGO SINUSA FLEBIT SEPTICHESKII, КАВЕРНОЗНОГО СИНУСА ТРОМБОЗ, КАВЕРНОЗНОГО СИНУСА ФЛЕБИТ СЕПТИЧЕСКИЙ, ФЛЕБИТ СЕПТИЧЕСКИЙ КАВЕРНОЗНОГО СИНУСА
Polish Zakrzepica zatoki jamistej
Hungarian sinus cavernosus thrombosis
Spanish trombosis del seno venoso cavernoso (trastorno), trombosis de seno venoso cavernoso, trombosis de seno venoso cavernoso (trastorno), trombosis del seno venoso cavernoso, Trombosis del seno cavernoso, Trombosis del Seno Cavernoso
Norwegian Sinus cavernosus-trombose
Dutch caverneus; trombose, trombose; caverneuze, sinus cavernosus trombose, Sinus-cavernosustrombose, Trombose van de sinus cavernosus, Trombose, sinus-cavernosus-
Portuguese Trombose do seio cavernoso, Trombose do Corpo Cavernoso
German Thrombose des Sinus cavernosus, Sinus-cavernosus-Thrombose, Thrombose, Sinus cavernosus
French Thrombose du sinus caverneux