Cavernous Sinus Thrombosis

1. Pathophysiology
   1. Most common infection of dural sinus thrombosis
   2. Sources
      1. Mid-face infections near the eyes and nose (e.g. nasal Furuncle)
      2. Sphenoid Sinus or Ethmoid Sinus infection
      3. Dental Infection (uncommon)
2. Symptoms
   1. Initial (first 1-2 days)
      1. Headache (most common
         1. Sharp pain increasing in severity becoming refractory and interferes with sleep
         2. Unilateral frontal and retroorbital Headache (Trigeminal Nerve ophthalmic and Maxillary branches)
   2. Next
      1. Fever
      2. Eye swelling
      3. Chemosis
      4. Diplopia
      5. Altered Level of Consciousness
3. Signs
   1. Classic, severe presentation
      1. Fever
      2. Bilateral Ptosis
      3. Proptosis
      4. Ocular muscle paralysis
   2. Eye findings
      1. Lateral gaze palsy (CN 6)
      2. Eye looks down and laterally (CN 3)
      3. Eyelid Ptosis
      4. Mydriasis
      5. Fundus Exam (abnormal in two thirds of patients)
         1. Papilledema
         2. Dilated tortuous Retinal veins
   3. Other neurologic findings
      1. Trigeminal Nerve (CN 5) deficits
4. Imaging
   1. Orbital CT with contrast
   2. MRI with gadolinium enhancement
5. Management
   1. Antibiotics
      1. MRSA coverage and initial empiric management
         1. Vancomycin 15-20 mg/kg (up to 2 g) IV every 8-12 hours AND
         2. Ceftriaxone 2 g IV every 12 hours or Cefepime 2 g IV every 8-12 hours
         3. Add Metronidazole 500 mg every 8 hours for Dental Infection (or higher dose for Brain Abscess)
      2. MSSA coverage (if confirmed by culture)
         1. Nafcillin or Oxacillin 2 g IV every 4 hours
   2. Anticoagulation
      1. Heparin (still recommended as of 2016)
   3. Glucocorticoids
      1. Dexamethasone 10 mg IV every 6 hours
   4. Surgery
      1. Emergent surgical drainage of Sphenoid Sinus should be considered
6. References
   1. Southwick (2016) Septic Dural Sinus Thrombosis, UpToDate, accessed online 4/8/2016
   2. (2016) Sanford Guide, accessed on IPad App 4/8/2016