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Cavernous sinus
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Cavernous sinus thrombosis

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Cavernous sinus thrombosis

  1. 1. Dr. Parag Moon Senior resident GMC, Kota
  2. 2.  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.
  3. 3.  Relations: ◦ Medial – pituitary above, sphenoidal air cell below ◦ Lateral – temporal lobe, uncus ◦ Anterior - superior orbital fissure ◦ Posterior - petrous apex ◦ Superior – optic chiasm
  4. 4.  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
  5. 5.  Communication: – Intercavernous sinuses – communication between the 2 – Pterygoid plexus – via emissary veins passing through foramen ovale, emissary sphenoidal foramen and foramen lacerum. – Pharyngeal plexus – via a vein passing through carotid canal. – Facial vein – via superior opthalmic vein.
  6. 6. Contents of cavernous sinus  - Internal Carotid artery with sympathetic plexus  - CN 3  - CN 4  - CN 5 (1st and 2nd divisions)  - CN 6
  7. 7.  Includes cases of phlebitis, thrombo-phlebitis and aseptic thrombosis  Septic type (most common) - coagulase positive staphylococcus  Aseptic types may follow trauma, local stasis or a failing circulation.
  8. 8. Septic CST  Infectious Aseptic CST  Trauma  Post surgery Rhinoplasty Base of skull Tooth extraction  Hematologic  Malignancy Nasopharyngeal Ca.  Dehydration
  9. 9.  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 Rhizopus species(more common in diabetics)
  10. 10.  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
  11. 11.  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
  12. 12. 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%
  13. 13. 1. Sepsis 2. Venous obstruction 3. Involvement of cranial nerves
  14. 14.  Pyrexia  Rapid, weak, thready pulse  Chills and sweats  Delirium - meningitis supervenes terminally  Septic emboli to various other parts of body.
  15. 15.  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
  16. 16.  First CN involved is VI  Ptosis - paralysis of oculomotor nerve  Dilatation of pupil- third nerve and stimulation of sympathetic plexus  Decreased abduction (paralysis of abducens nerve)  Complete opthalmoplegia  Loss of vision  Retro-orbital pain and supra-orbital headache->V
  17. 17.  Strong clinical suspicion 1)Orbital venography  Not recommended  Difficult to puncture facial veins in odema  May help in dissemination of infection
  18. 18. 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
  19. 19. 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
  20. 20. 4) CSF examination  Elevated protein  Normal sugar  Mild pleocytosis 5) Complete blood count  Elevated TLC  Leucocytosis 6) Blood culture 7) Local tissue culture
  21. 21.  Intracranial extension of infection-> meningitis, encephalitis, brain abcess, pituitary infection,epidural, subdural empyema  Cortical vein thrombosis->hemorrhagic infarction  Extension to other sinuses
  22. 22.  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, periorbital odema  Sinusitis  Orbital malignancy  Facial Cellulitis  Glaucoma-angle closure
  23. 23.  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+vancomycin with metronidazole  Duration- 3-4 weeks
  24. 24.  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)
  25. 25.  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
  26. 26.  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.
  27. 27.  Not influence mortality  May prevent residual cranial nerve dysfunction caused by inflammation.  Dexamethasone used most commonly
  28. 28.  Surgical drainage of affected sinuses  Endoscopic sinus surgery  Surgical debridement in fungal sinusitis  Surgical drainage of any collection
  29. 29.  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.
  30. 30.  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
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