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Cavernous Sinus Thrombosis

by James Garrity, MD

Cavernous sinus thrombosis is a very rare disorder in which a blood clot (thrombosis) forms in the cavernous sinus (a large vein at the base of the skull).

  • The disorder is usually caused by the spread of bacteria from infections of the face (including the skin of the nose) or sinus.

  • Symptoms include head and facial pain, visual disturbances, bulging eyes, and high fever.

  • The diagnosis is based on symptoms and the results of magnetic resonance imaging or computed tomography.

  • Even with treatment, the disorder can result in severe aftereffects or be fatal.

  • High doses of antibiotics are given to eliminate the infection.

The cavernous sinus is a large vein at the base of the skull, behind the eyes. This vein drains blood from veins in the face. The cavernous sinus is not one of the air-filled sinuses around the nose (the nasal sinuses).

Causes

Cavernous sinus thrombosis (CST) is usually caused by the spread of bacteria (usually Staphylococcus aureus) from a facial, dental, or nasal sinus infection. CST can be caused by common facial infections such as small nasal boils around hair follicles (furuncles) or sinusitis of the sphenoid or ethmoid sinuses. Why the clot forms is not completely understood. Because CST is a possible complication, doctors always consider infections in the area around the nose to the rims of the eyes serious. CST can affect the cranial nerves (see Overview of the Cranial Nerves) near the cavernous sinus that move the eyes and supply sensation to the face. CST can also lead to an infection of the brain and the fluid around the meninges (meningoencephalitis), brain abscess, stroke, blindness, and an underactive pituitary gland (hypopituitarism—see Hypopituitarism).

Symptoms

CST causes symptoms such as abnormally bulging eyes (proptosis), swelling of the eyelid, severe headache, facial pain or numbness, impaired eye movements (ophthalmoplegia) with double vision, loss of vision, drowsiness, a high fever, and excessively dilated or uneven pupils. If bacteria spread to the brain, more severe drowsiness, seizures, coma, and abnormal sensations or muscle weakness in certain areas may develop.

Diagnosis

Magnetic resonance imaging (MRI) or computed tomography (CT) of the nasal sinuses, eyes, and brain is usually done. To identify the bacteria, a blood sample and samples of fluid, mucus, or pus from the throat and nose are sent to a laboratory to be cultured. A spinal tap (see Tests for Brain, Spinal Cord, and Nerve Disorders : Spinal Tap) may also be done.

Prognosis

Even with treatment, CST can still be life threatening. About 30% of all affected people and about 50% of affected people who also have sinusitis of the sphenoid sinuses die. Another 30% develop serious aftereffects (such as impaired eye movements and double vision, blindness, disability due to stroke, and hypopopituitarism), which may be permanent.

Treatment

High doses of antibiotics given by vein (intravenously) are started immediately. The infected nasal sinus may be drained surgically, particularly if the person does not improve after 24 hours of antibiotic treatment. Corticosteroids are sometimes given if the cranial nerves are affected. Corticosteroids and usually other supplemental hormones are given if there is hypopituitarism.