Cavernous Sinus Thrombosis
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- Thrombosis of a branch of the major intracerebral venous drainage system
- Most commonly infectious
- Spreads from facial, odontogenic, or sinus infection
- Less frequently occurs with hypercoagulable state
3 primary sites of thrombosis:
- Cavernous sinus—Most common:
- Drainage from superficial venous system
- Superolateral to the sphenoid sinus and surrounds the sella:
- Cranial nerves (CN) III, IV, V1, and V2 traverse the lateral wall of the sinus.
- CN VI and the internal carotid artery occupy the medial portion of the sinus.
- Can also involve transverse sinus and superficial sagittal sinus
- Hematogenous spread of facial, otic, or neck infection into venous drainage system
- Contiguous spread directly from infected sinus cavities (sphenoid, ethmoid > frontal)
- Bacterial overgrowth leads to inflammation and coagulation, resulting in thrombosis.
- Venous engorgement of cavernous sinus can affect adjacent structures:
- Ophthalmoplegia from inflammation of CN III, IV, or VI
- Pupillary fixation from CN III
- Sensory deficits or paresthesia of forehead or cheek from CN V1 and V2
- Staphylococcus aureus accounts for 70%
- Streptococcus pneumoniae, gram-negative bacilli, and anaerobes also seen
- Fungi less common; include Aspergillus and Rhizopus species
- Less common
- Granulomatous conditions (TB)
- Inflammatory disorders
- From mass effect (tumors at base of skull, aneurysms)
- Hypercoagulable states
- Children may present with nonspecific symptoms such as decreased energy, vomiting, fever.
- Have high level of suspicion for any child with recent otitis or pharyngitis with worsening symptoms, declining mental status, or signs of increased intracranial pressure (ICP):
- HTN, bradycardia, lethargy, vomiting, gait instability
- More common in the neonatal period, when diagnosis can be extremely difficult to make