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Official Publication of Orofacial Chronicle , India

www.jhnps.weebly.com

REVIEW ARTICLE

Cavernous Sinus Thrombosis A succinct outlook

Maliha Saman BDS
1
, Akheel Mohammad MDS
2
, S.P. Singh MCh
3

1- Consultant dental surgeon 2- Oral & Maxillofacial Surgeon, Chennai India
3- 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 be
aware 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 this Article: Maliha S., Akheel M.D, S.P. Singh: Cavernous Sinus thrombosis - A
succinct outlook : J ournal of Head & Neck physicians and surgeons Vol 2 Issue 1 2014 : Pg
67-72
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 fatal
1
. 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 eye
findings 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 thrombosis
4, 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 Aspergillus and
Rhizopus species
6, 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
channels
8
.

The general symptoms include fever present along with the 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 side
7, 8,9,10
.

DISCUSSION:

In 1732 Winslow coined the term cavernous sinus and later Dwight Parkisnson
referred it as the anatomic jewel box
1, 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
medially
11, 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 1.29:1
3, 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 rare
14
.
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 with
overlapping symptoms and should be kept in overview when treatment doesnt
seem to resolve the symptoms
13,15,16,17
.
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 vein
15, 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 of
intracranial bleeding but doesnt outweigh the benefit of recannulization and
dissolution of thrombus thus is emerging as a promising treatment modality
15,16,17
.

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 based
medical care CST demands the diagnostic skill of the physician whose prompt
intervention can yield a favourable result.



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15. Deshmukh, Vinayak, Bhavana Lakhkar, and Jayant Wagha. "CAVERNOUS SINUS
THROMBOSIS." (2008).
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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 - drmalihasaman@gmail.com
Contact 091- 08056259725