An assignment for IMU Semester One BDS programme. :)

1. CAVERNOUS SINUS THROMBOSIS
(CST)
FONG ZHAN YAN
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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. 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

5. 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

6. 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

7. 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

8. HOW??

9. 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

10. 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

11. 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 **

12. 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 **

13. 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

14. 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


15. 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.

16. 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

17. 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. MANAGEMENT FOR CST

19. 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

20. 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

21. 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