Cavernous Sinus Thrombosis

Cavernous Sinus Thrombosis is a topic covered in the 5-Minute Emergency Consult.

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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


  • Septic:
    • Staphylococcus aureus accounts for 70%
    • Streptococcus pneumoniae, gram-negative bacilli, and anaerobes also seen
    • Fungi less common; include Aspergillus and Rhizopus species
  • Aseptic:
    • Less common
    • Granulomatous conditions (TB)
    • Inflammatory disorders
    • From mass effect (tumors at base of skull, aneurysms)
  • Hypercoagulable states

Pediatric Considerations
  • 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

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