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OVERVIEW
Introduction
Development
Anatomy
o
o
Structures within
Structures
around
Tributaries
Cavernous Sinus
Thrombosis
o
o
o
o
o
Clinical
Presentation
Danger Area of the
Face
Investigations
Neuroradiology
Complications
Treatment
INTRODUCTION
The space or compartment commonly called the
cavernous sinus is a veritable anatomical jewel box
containing more significant structures than any
other comparable space outside the brain itself.
(Parkinson 1990)
Cavernous+ Sinus
Cavernous- Cavern: A large cave or chamber in a cave
specific type of cave, naturally formed in soluble rock with the
ability to grow speleothems
3
Dural Sinuses
Lie between the endosteal and meningeal
layers of dura mater
Are lined by endothelium, firm collagenous
tissue
Have no valves
Walls are devoid of muscular tissue
Numerous lacunes and trabeculae
5
DEVELOPMENT
Padget (1956)
Cavernous sinus Plexiform extension of prootic
sinus and ventral myelencephalic vein
Superior ophthalmic v Primitive maxillary v as
it drains into the prootic sinus, and develops into
the superior ophthalmic vein which drains
directly into the cavernous sinus.
7
40 mm
60 mm
3rd
month
Adult
Knosp (1987)
20% of fetal skull bases- SMCV drains into the
Cavernous Sinus
60% of fetal skull bases- SPS and Cavernous
Sinus show a connection
Hence developmental basis for varied pattern of
venous tributaries and drainage
9
ANATOMY
Number
2, Paired
Dimensions
Length 20mm
Width 09mm
Location
Middle Cranial Fossa
Either side of body of
sphenoid
Extent
From Superior Orbital
Fissure to the Petrous apex of
Temporal bone
Shape
Triangular in cross section,
Boat shaped
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12
STRUCTURES WITHIN..
CONTENTS
Cavernous
Sinus
Central
Structures
Lateral wall
culomoto
rn
CN3
Trochlear n
CN4
Maxillary n
CN V2
Ophthalmic
n
CN V1
ICA
Abducens n
CN 6
13
14
Anatomical Relations
Osseou
s
Relatio
ns
Dural
Relatio
ns
Caverno
us sinus
Vascul
ar
Relatio
ns
Neural
Relatio
ns
15
16
Osseous Relations
ANTERIO
R
MEDIA
L
LATERA
L
Optic
strut
Caroticoclinoid
foramen
Greater
wing of
sphenoid
Anterior
clinoid
process
Middle
clinoid
process
Foramina
Lesser
wing of
sphenoid
Pituitary
fossa
Body of
sphenoid
Carotid
sulcus
(rotundu
m, ovale,
spinosu
m)
POSTERIOR
Posterior
Cliniod
Process
Dorsum
Sella
Petrous
Apex
Trigemin
al
Impressi
on
17
18
19
CLINICAL SIGNIFICANCE OF
OSSEOUS RELATIONS
In surgically exploring cavernous sinus, an
initial step is to unlock the contents of the
sinus from the bony confines.
This step includes unroofing and mobilizing the
optic nerve, and then removing anterior clinoid
process.
This phase can be performed in an extradural or
intradural fashion.
DURAL RELATIONS
Superior
Inferior
Dura Mater
Tentorium
Cerebelli
Periosteum
floor
Medial
Lateral
Endosteum
of Sella
turcicas
Lateral
wall
Dura
Propria of
uncus of
temporal
lobe
ROOF
Anterior extension of
the Tentorium
Cerebelli
Lateral extension of
Diaphragma Sella
22
Posterior
Wall
Lower
margin
shared with
basilar
sinus,
pierced by
Abducens n
Upper edgeposterior
petroclinoid
al fold
23
Medial Wall
Dura covering
the lateral
aspect of the
Sella turcica
and the lateral
surface of
body of
Sphenoid bone
24
Lateral
wall
Dura
propria of
Uncus of
the
temporal
lobe
25
26
27
NEURAL RELATIONS
Cranial nerves III to VI are closely related to cavernous sinus.
Oculomotor Nerve
CN III
Courses
lateral to
PCP
Exits
through
SOF
Enters
Cavernous
sinus on
superolateral
surface
Passes along
inferolateral
surface of
ACP
Passes lateral
to the
cavernous
sinus
Here its
epineurium
interweaves
with that of
CN IV
29
Superior
division
Levator
Palpebrae
Superioris
Superior
Rectus
Inferior
Division
Medial and
inferior
recti
Inferior
Oblique
30
Trochlear Nerve
Trochlear nerve enters the roof
of the sinus posterolateral to
the oculomotor nerve
31
Ophthalmic Nerve
32
33
Abducens Nerve
The abducens nerve pierces the dura
Forms lower part of the posterior wall of the
sinus
At the upper border of the petrous apex,
enters Dorellos canal
34
Clinical Significance
Cranial nerve palsy is the most common manifestation of
pathologic processes involving the cavernous sinus.
Diplopia, Sixth nerve palsy with Horners Syndrome, impaired
visual acuity may suggest cavernous sinus lesions.
Most cavernous sinus explorations are for benign disease
with the goal of preserving and improving cranial nerve
function.
Exploration of cavernous sinus usually follows mobilization of
lateral wall and entry through one or more of the various
triangles formed by these cranial nerves and dural folds.
35
Anatomic Triangles
Vascular Relations
Arterial Relations
Internal Carotid
Artery and its
anatomically
divided course Petrous
Cavernous
Intracranial
Venous
Relations
Afferent
Tributaries
Efferent
Drainage
37
38
Initially runs
vertically,
becomes
horizontal in
Petrous
part
the
petrous
temporal bone
(C2)
POSTERIOR
LOOP
Crosses For.
Lacerum under
Trigeminal
ganglion
Ascends
towards
Cavernous
Sinus (C3)
LATERAL LOOP
39
Enters
cavernou
s sinus
through
the
posterior
aspect
Ascends
towards
Posterior
Clinoid
Process
Becomes
Horizonta
l (C4)
MEDIAL
LOOP
After
horizonta
l course
through
sinus, it
reverses
its
course
Reaches
towards
lateral
aspect of
ACP
Exits
from
sinus
(C5)
ANTERIO
R LOOP
Anterior
loop is
oriented
at 30
degrees
to the
horizonta
l plane
40
41
Inferior
hypopheseal
Meningohypophys
eal trunk from C5
Intracranial
ICA
In the
cavernous
segment
Tentorial
Clival (Dorsal
Meningeal
Inferolateral
Trunk (Inf Cav
Artery to CN
Sin Br.) from
3,4,6
C4
Mc Connells
Sella turcica,
Capsular Artery from
roof and floor
C4
42
Veinous relations
Tributaries (afferent
veins):
Superior ophthalmic vein
(SOV)
Inferior ophthalmic vein
(IOV)
Central retinal vein
Superficial middle cerebral
vein (SMCV)
Uncal vein (UV)
Sphenoparietal sinus (SPPS)
Meningeal veins
43
Drainage (efferent
veins):
Foramen ovale plexus (FOP)
Vein of the foramen
rotundum
Pterygoid plexus (PP)
Internal jugular vein (IJV)
Facial vein (FV)
Angular vein (AV)
Retromandibular vein
Supraorbital vein
Frontal vein (FrV)
44
45
46
COMMUNICATIONS OF
CAVERNOUS SINUS
Venous blood from the brain flows via the superficial( cortical)
and the deep cerebral veins into the venous (dural) sinuses.
There are numerous connections between the cortical veins
and dural sinuses.
This facilitates the spread of thrombus infection between
these vessels.
Also allows opening of collateral draining vessels in the event
of an occlusion.
Summary of communication
The cavernous sinuses receive blood from
cerebral veins
the ophthalmic veins (from the orbit)
emissary veins (from the pterygoid plexus of veins in the infratemporal
fossa).
49
Midbrain Infection
Cavernous Sinus Thrombosis
Orbital Fracture
Petrous Bone Fracture (Temporal bone Fracture )
Internal Carotid Artery Aneurysm
Mastoiditis
Increased Intracranial Pressure
Emissary Veins
Emissary Syn.
ambassador
From skull veins to
external veins
Importance- to maintain
intracranial and
extracranial venous
pressure at an equilibrium,
valve-less to ensure the
same.
May carry Infected
thrombus from
extracranial to intracranial
53
CAVERNOUS SINUS
THROMBOSIS
Thrombosis of the cavernous sinus is one of the most
dramatic of neuro-ophthalmic conditions.
Within a short period, a swollen orbit, limited ocular
motility and impaired vision develop, and may progress
to a life threatening condition
Rapid diagnosis and therapeutic action are required.
Morbidity is high, and outcome cannot be certain.
54
Epidemiology
Frequency:
Mortality/ morbidity:
Race : no predilection
Sex: no predilection
55
Direct Spread
Spread by direct extension via
the infratemporal space
through the cranial wall
By way of pterygoid plexus and
emissary veins, against the
usual flow.
This is possible because of the
anatomic anomaly of the
absence of valves in the
Heamatogenous
Spread
Intranasal operations on
through the ethmoidal veins.
the septum, turbinates or
ethmoid/ sphenoid sinus
infection
Operations on the tonsil,
peritonsillar abscess, surgery spread by pterygoid plexus or by direct
or osteomyelitis of the
extension to the internal jugular vein.
maxilla, dental extraction
and deep cervical abscess
Ptosis
Proptosis
Chemosis
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Clinical history
Patient generally have sinusitis or a midface infection
(most commonly a furuncle) for 5-10 days. In as many
as 25% of cases in which a furuncle is the precipitant, it
will have been manipulated in some fashion(eg:
squeezing, surgical incision.)
Headache, fever, and malaise typically precede the
development of ocular findings. As the infection tracts
posteriorly, patient complains of orbital pain and
fullness accompanied by periorbital edema and visual
disturbances.
In some patients, periorbital findings do not develop
early on and the clinical picture is subtle.
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Etiology
Staphylococcus aureus is the most common
infectious microbe, found in 50% to 60% of the
cases. Streptococcus pneumoniae is the second
leading cause.
Gram-negative rods and anaerobes may also
lead to cavernous sinus thrombosis.
Rarely, Aspergillus fumigatus, Mucormycosis,
Haemophilus influenzae cause CST.
BACTERIOLOGY
Children
H. influenzae
Staph. aureus
Strep. Pneumoniae
Adults
Mixed infections
Aerobes
Anaerobes
Bacteroides
Veillonella
Peptostreptococci
Strep. milleri
Strep. constellatus
Complications
Intracranial extension of infection may result in
meningitis, encephalitis, brain abscess,
pituitary infection, and epidural and subdural
empyema.
Cortical vein thrombosis can result in
hemorrhagic infarction.
Extension of the thrombus to other sinuses can
occur.
CST
Increased
venous
congestion
Increased
venous sinus
&CSF pressure
Cerebral
haemorrhage
& infraction
Systemic
embolism
Hypopituitaris
m
Pulmonary
embolism
(10-20%)
73
Differential Diagnosis
Orbital cellulitis
Intraorbital abscess
Intracavernous carotid artery aneurysm or Arteriovenous
fistulae
Idiopathic granulomatous inflammation of the superior orbital
fissure and cavernous sinus(Tolosa-Hunt syndrome)
Periarteritis nodosa associated with cavernous sinus
thrombosis (Cogans syndrome)
Nasopharyngeal tumor
Meningeoma
Trauma
Antibiotic therapy:
Oxacillin
Ceftriaxone
Metronidazole
80
Anticoagulant therapy:
Augments activity of antithrombin III and prevents
conversion of fibrinogen to fibrin.
Does not actively lyse thrombus but inhibits further
thrombogenesis.
Prevents re-accumulation of clot after spontaneous
fibrinolysis.
Corticosteroid therapy:
Corticosteroids may help to reduce inflammation and
edema and should be considered as an adjunctive
therapy.
These agents have anti inflammatory properties and
cause profound and varied metabolic effects. When the
course of CST leads to pituitary insufficiency,
corticosteroids definitely are indicated to prevent adrenal
crisis.
82
Prognosis
Following the acute phase of infection, recovery is
gradual
Up to 50% of patients can have long-term neurological
deficits in the form of decreased visual acuity, diplopia,
cranial nerve deficits, hemiparesis, ataxia or epilepsy.
The majority of reported cranial nerve deficits have
involved the occulomotor and abducens nerves. Longterm follow-up of these patients is essential as relapses
have been reported after apparent clinical resolution.
Recent studies have shown a mortality rate closer to
10%
CONCLUSION
85
REFERENCES
Grays anatomy
Cavernous Sinus- Developments and future perspectibes- Vinko Dolenc
Neelima Malik 3rd edition
Oral and Maxillofacial infections; Laskin
Contemporary oral and maxillofacial surgery ; Peterson
Operative neurosurgical techniques; Henry Schmidek
Complications of head and neck surgery; Krespi and Ossoff
Anatomy for surgeons: The head and Neck, vol 1; hollinshead
Maxillofacial infections ; Topazian, 4 th edition
Brains diseases of nervous system 10 th edition; John Walton
Color atlas of clinical neurology 2 nd edition; Malcom Parson
Cavernous sinus thrombosis and blindness as complications of an
odontogenic infection; J Oral Maxillofac Surg 47 1317-1321,1989
Ocular manifestations of cavernous sinus thrombosis- V Visvanathan, S
Uppal, S Prowse; BMJ Case Reports 2010
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THANK YOU!!
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