Cavernous sinus thrombosis

1. Cavernous sinus thrombosis recent advances Dr. Parag Moon Senior resident GMC, Kota

2. Anatomy of cavernous sinus

3. 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.

4. Relations: Medial – pituitary above, sphenoidal air cell below Lateral – temporal lobe, uncus Anterior - superior orbital fissure Posterior - petrous apex Superior – optic chiasm

5. 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

6. 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.

7. Contents of cavernous sinus - Internal Carotid artery with sympathetic plexus - CN 3 - CN 4 - CN 5 (1 st and 2 nd divisions) - CN 6

8. Cavernous sinus thrombosis

9. 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.

10. Causes Septic CST Infectious Aseptic CST Trauma Post surgery Rhinoplasty Base of skull Tooth extraction Hematologic Malignancy Nasopharyngeal Ca. Dehydration

11. 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)

12. 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 Spread of infection

13. 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 Spread of infection

14. 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%

15. Sepsis Venous obstruction Involvement of cranial nerves Clinical features

16. Pyrexia Rapid, weak, thready pulse Chills and sweats Delirium - meningitis supervenes terminally Septic emboli to various other parts of body. Sepsis

17. 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 Venous obstruction

18. 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 Involvement of cranial nerves

19. Strong clinical suspicion 1)Orbital venography Not recommended Difficult to puncture facial veins in odema May help in dissemination of infection Diagnosis

20. 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

21. 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

22. 4) CSF examination Elevated protein Normal sugar Mild pleocytosis 5) Complete blood count Elevated TLC Leucocytosis 6) Blood culture 7) Local tissue culture

23. Intracranial extension of infection-> meningitis, encephalitis, brain abcess , pituitary infection,epidural , subdural empyema Cortical vein thrombosis->hemorrhagic infarction Extension to other sinuses Complications

24. 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 Differential Diagnoses

25. Treatment

26. 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 Antibiotics

27. 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) Antifungals

28. 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 Anticoagulation

29. 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.

30. Not influence mortality May prevent residual cranial nerve dysfunction caused by inflammation. Dexamethasone used most commonly Steroids

31. Surgical drainage of affected sinuses Endoscopic sinus surgery Surgical debridement in fungal sinusitis Surgical drainage of any collection Surgical treatment

32. 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. Prognosis

33. Thanks

34. 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 References