Cavernous Sinus Thrombosis – A succinct outlook

8/12/2019 Cavernous Sinus Thrombosis A succinct outlook

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Official Publication of Orofacial Chronicle , India

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REVIEW ARTICLE

Cavernous Sinus Thrombosis A succinct outlook

Maliha Saman BDS1, Akheel Mohammad MDS

2, S.P. Singh MCh

3

1- Consultant dental surgeon 2- Oral & Maxillofacial Surgeon, Chennai India3- Neuro and spine surgeon, Bhopal, India

ABSTRACT:

Cavernous sinus thrombosis is generally a fulminant process with high rates of

morbidity and mortality. The diagnostic incidence of Cavernous Venous

Thrombosis is increasing to 7 per 1,000, 000 as newer and more advanced imaging

modalities emerge off late and hence every oral & maxillofacial surgeon must beaware of its occurrence and appropriate immediate management protocol. This

article would throw light on anatomy, pathophysiology, clinical features,

radiodiagnosis and management of Cavernous Sinus Thrombosis.

Key Words: Cavernous sinus , thrombosis , management

Cite thi s Ar ticle: M aliha S., Akheel M .D, S.P. Singh: Cavernous Sinus thrombosis - A

succinct outl ook : Journal of Head & Neck physicians and surgeons Vol 2 Issue 1 2014 : Pg67-72

INTRODUCTION:

Cavernous sinus thrombosis is generally a fulminant process with high rates of

morbidity and mortality. It was first described by Dease in 1778 as a rare,


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potentially fatal complication of dental infections, orbital cellulitis, and sinusitis.

Intracranial complications of dental abscess are very rare, but could be fatal1. Later

the striking syndrome of swollen orbit , limited ocular mobility , impaired vision

was first pathologically recognized by Duncan in 1821 and later clinically defined

by Bright in 1831 as a complication of epidural and subdural infections and eyefindings by Knapp in 1868

2,3. This article would throw light on anatomy,

pathophysiology, clinical features, radiodiagnosis and management of Cavernous

Sinus Thrombosis.

PATHOPHYSIOLOGY:

Aseptic thrombosis occurs with trauma, tumor invasion, aneurysmal expansion and

hypercoaguable states whereas septic thrombosis is more common and occurs due

to the intimate juxtaposition of veins, arteries, nerves, meninges, and paranasal

sinuses accounting for the characteristic etiology and presentation. CST is more

commonly seen with sphenoid and ethmoid and to a lesser degree with frontal

sinusitis.Due to its complex neurovascular anatomic relationship, cavernous sinus

thrombosis is the most important of any intracranial septic thrombosis4, 5

.

Staphylococcus aureus accounts for approximately 70% of all infections.

Streptococcus pneumoniae, gram-negative bacilli, and anaerobes can also be seen.

Fungi are a less common pathogen and may include Aspergillusand

Rhizopusspecies6, 7, 8

. Another reason for the pathogenesis can be due to mycotic

embolism where following a trauma to middle third of face could lead to an

emoboli which could get lodged into the cavernous sinus producing CST

symptomology. Another pathophysiology behind CST could be explained due to

phelbothrombosis occurring in cavernous sinus or any of the connecting vein

channels8.

The general symptoms include fever present along withthe Ocular signs following

a thrombosis of cavernous sinus include proptosis and edema of lips and

conjunctiva and paresis of nerve supplied by Occulomotor, Trochlear and

Abducent nerves when involved. Chemosis, Papilledema, Periorbital sensory loss,

Decreased corneal reflex, nuchal rigidity are other associating features presentable.


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In conditions of oculomotor nerve involvement parasympathetic and sympathetic

denervation leads the pupils to become small and immobile. Bilateral

symptomology can be explained due to the involvement of intercavenous sinus as a

result of free communication that presents on either side7, 8,9,10

.

DISCUSSION:

In 1732 Winslow coined the term cavernous sinus and later Dwight Parkisnson

referred it as the anatomic jewel box1, 9, and 10

. The Brains venous channels include

the dural venous sinuses and are valveless located between the inner and outer

layers of dura extending extradurally from the superior orbital fissure backward to

apex of petrous part of temporal bone. The cavernous sinuses lie on either side of

pituitary fossa and are interconnected by intercavernous sinus presenting the

primary venous reservoir for outflow of superior and inferior ophthalmic veins,

cerebral veins and sphenoparietal sinus. It communicates to transverse sinus via

superior petrosal sinus. The important structures that surround the cavernous sinus

include Occulomotor, Trochlear, Ophthalmic and Maxillary nerves laterally; along

with Internal carotid artery and the sympathetic plexus and Abducent nerve

medially11, 12, and 13

.

The diagnostic incidence of Cavernous Venous Thrombosis is increasing to 7 per 1

000 000 as newer and more advanced imaging modalities emerge off late. Females

are more commonly affected than males, with a ratio of 1.29:13, 14

. It presents more

commonly among women in the 2035 year age group. There is no race

predilection, and the associated mortality is reported to be 7%. Prospective studies

have reported an independent survival rate of approximately 80%. Prior to the

advent of effective antimicrobial agents, the mortality rate from CST was

effectively 100%. With aggressive management, the mortality rate is now less than

30%. Morbidity, however, remains high, and complete recovery is rare14

.

In 1926 Eagleton suggested 6 criteria which are now considered as the guidelines

for diagnosis 1) a known site of infection 2) septicemia 3) early signs of venous

congestion 4) ocular, maxillary, abducent nerve defecits 5) abscess or phlebitis

contagious to cavernous sinus & 6) signs of intracranial infection though all these


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features need not be sought but definite findings are sufficient to conclude a

diagnosis. The most suspected differential diagnosis should include toxemia as an

intravascular bacterial infection can present with aforesaid symptoms. Orbital vary,

Orbital apex syndrome, Superior orbital fissure Syndrome, pseudotumour of orbit ,

mucormycosis , orbital cellultis and acute ethmoiditis also present withoverlapping symptoms and should be kept in overview when treatment doesnt

seem to resolve the symptoms13,15,16,17

.

Imaging studies remain the cornerstone of diagnosis. The diagnosis of cerebral

venous sinus thrombosis is made on the appearance of the delta sign, a feature

which is frequently absent on CT scans unlike scleral thickening, swollen ocular

muscles and retrobulbar densities which are classically appreciated. The imaging

modality of choice is magnetic resonance venography as it allows direct

visualisation of the dural venous sinuses and the large cerebral veins. It is an

invasive procedure with catheterisation of the jugular vein15, 16

.

Treatment can be broadly classified into either being aggressive or emergency

management. The primary choice of medicine should be penicillin or a

combination of synthetic penicillin which should be administered intravenously in

the highest recommended dosage. Treatment options for cerebral venous sinus

thrombosis also include anticoagulation, thrombolytic therapy, and, in some cases,

surgical thrombectomy. Anti coagulant therapy is a bit controversial due to risk ofintracranial bleeding but doesnt outweigh the benefit of recannulization and

dissolution of thrombus thus is emerging as a promising treatment modality15,16,17

.

CONCLUSION:

In summary CST is still with us, though patients now have better survival rates. It

is a disease primarily diagnosed with physical signs and symptoms, which requires

prompt treatment. In our modern age of Computerization and laboratory basedmedical care CST demands the diagnostic skill of the physician whose prompt

intervention can yield a favourable result.


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REFERENCES:

1. Zahller, M., et al. "Cavernous sinus thrombosis." Western Journal of Medicine133.1(1980): 44.

2. Seltzer, Albert P. "Cavernous Sinus Thrombus with Antral Infection."Journal of theNational Medical Association54.6 (1962): 673.

3. Rael, Jesse R., et al. "Direct thrombolysis of superior sagittal sinus thrombosis withcoexisting intracranial hemorrhage."American journal of neuroradiology18.7 (1997):1238-1242.

4. Clifford-Jones, R. E., et al. "Cavernous sinus thrombosis."Journal of Neurology,Neurosurgery & Psychiatry45.12 (1982): 1092-1097.

5. Stam, Jan. "Thrombosis of the cerebral veins and sinuses."New England Journal ofMedicine352.17 (2005): 1791-1798.

6. Acheson, J., and A. Malik. "Cerebral venous sinus thrombosis presenting in thepuerperium."Emergency medicine journal: EMJ23.7 (2006): e44.

7. Karlin, Ronald J., and William A. Robinson. "Septic cavernous sinus thrombosis."Annals of emergency medicine13.6 (1984): 449-455.

8. Fink, J. N., and D. L. McAuley. "Cerebral venous sinus thrombosis: a diagnosticchallenge."Internal medicine journal31.7 (2001): 384-390.

9. Sekhar, Laligam N., Manuel Dujovny, and Gutti R. Rao. "Carotid-cavernous sinusthrombosis caused by Aspergillus fumigatus: case report."Journal of neurosurgery52.1

(1980): 120-125.10.Bentley, J. Nicole, Ramn E. Figueroa, and John R. Vender. "From presentation to

follow-up: diagnosis and treatment of cerebral venous thrombosis."Neurosurgical focus

27.5 (2009): E4.11.Yarington Jr, C. Thomas. "Cavernous sinus thrombosis revisited."Proceedings of the

Royal Society of Medicine70.7 (1977): 456.

12.Levine, Steven R., Roy E. Twyman, and Sid Gilman. "The role of anticoagulation incavernous sinus thrombosis."Neurology38.4 (1988): 517-517.

13.Bousser, M-G. "Cerebral venous thrombosis: diagnosis and management."Journal ofneurology247.4 (2000): 252-258.

14.Masuhr, F., and S. Mehraein. "Cerebral venous and sinus thrombosis."Journal ofneurology251.1 (2004): 11-23.

15.Deshmukh, Vinayak, Bhavana Lakhkar, and Jayant Wagha. "CAVERNOUS SINUSTHROMBOSIS." (2008).

16.Levine, Steven R., Roy E. Twyman, and Sid Gilman. "The role of anticoagulation incavernous sinus thrombosis."Neurology38.4 (1988): 517-517.

17.Bhatia, K., and N. S. Jones. "Septic cavernous sinus thrombosis secondary to sinusitis:are anticoagulants indicated? A review of the literature." The Journal of Laryngology &

Otology116.09 (2002): 667-676.

Acknowledgement-None


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Source of Funding-Nil

Conflict of Interest-None Declared

Ethical Approval-Not Required

Correspondence Addresses :

Maliha Saman

Consultant Dental Surgeon

Chennai, India

Email Id - [email protected]

Contact091- 08056259725
mailto:[email protected]:[email protected]:[email protected]

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Cavernous Sinus Thrombosis – A succinct outlook