Download Cavernous Sinus Thrombosis

C.M. Aderman, HMSIII
G. Lieberman, MD
Cavernous Sinus Thrombosis
Christopher M. Aderman, HMS year III
Dr. Gillian Lieberman, MD
April 2011
C.M. Aderman, HMSIII
G. Lieberman, MD
Agenda
• Patient presentation
• Relevant anatomy
• Cavernous sinus thrombosis
– Classic signs and symptoms
– Pathogenesis
• Differential diagnosis
• Case resolution
• Menu of radiologic tests
• Companion cases • Radiologic imaging
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C.M. Aderman, HMSIII
G. Lieberman, MD
Objectives
1. Learn the clinical presentation and differential diagnosis for cavernous sinus thrombosis
2. Understand the menu of radiologic tests available
3. Review orbital anatomy
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C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: HPI
• 18 year old woman presented to university health center with fever, headache, cough, neck lymphadenopathy
– Diagnosed with “infectious mononucleosis”
• Several days later, she became lethargic and started to have rigors, admitted to OSH
• At OSH, WBC: 17.7 (4% bands), creatinine: 2.5, BP: 80/40's, and GNR in blood
• Antibiotics were initiated • The following morning, awoke with right facial numbness, double vision, and inability to open right eye
• She was transferred to BIDMC for further care
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C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Medical History
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PMH: No medical history or hospitalizations
Allergies: NKDA Medications: Ibuprofen as needed, no OCP
Social Hx: College student, lives in the dorm; denies smoking, alcohol or illicit drug use. • Family Hx: No history of strokes or hypercoagulability
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C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Physical Exam
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Vitals: T:99°F BP:99/50 HR:102 RR:36 O2 sat:99%
Gen: Lying in bed, fatigued, NAD HEENT: NC/AT, moist oral mucosa
Neck: Supple, no tenderness to palpation, normal ROM, no carotid or vertebral bruit; neck lymphadenopathy
Back: No focal tenderness or erythema
CV: RRR, normal S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally
Abd: Soft, nontender , nondistended, normoactive bowel sounds
Ext: No edema
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C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Neurologic Exam
• Neuro:
– Left cranial nerves II‐XII intact – Right eye papilledema, blurred disc margin
– Right pupil 6 mm sluggish, cannot adduct or move eye superiorly or inferiorly
– Right eye ptosis
– Pain with eye movements
– Diminished sensation in V1 and V2, sensation normal in V3 on right
– Sensation, strength, reflexes, coordination normal
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C.M. Aderman, HMSIII
G. Lieberman, MD
It appears that multiple cranial nerves are
involved. Can we localize these
abnormalities to one lesion in the brain?
Let’s review the relevant anatomy.
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C.M. Aderman, HMSIII
G. Lieberman, MD
Orbital Apex Anatomy
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Drake, et al, Fig 8.83
C.M. Aderman, HMSIII
G. Lieberman, MD
Muscles at the Orbital Apex
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Drake, et al, Fig 8.90
C.M. Aderman, HMSIII
G. Lieberman, MD
Orbital Anatomy
Let’s review some anatomy on this coronal C+ CT at the level of the orbits.
CNII (optic nerve)
CNIII (oculomotor)
Medial rectus
Superior rectus
Inferior rectus CNIV (trochlear)
Superior oblique CNVI (abducens)
Lateral rectus
Superior ophthalmic vein
PACS, BIDMC
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C.M. Aderman, HMSIII
G. Lieberman, MD
Orbital Venous Drainage
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Drake, et al, Fig 8.93
C.M. Aderman, HMSIII
G. Lieberman, MD
Venous Drainage of the Skull
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Drake, et al, Fig 8.43
C.M. Aderman, HMSIII
G. Lieberman, MD
Cavernous Sinus Anatomy
The cavernous sinus extends from the superior orbital fissure to the petrous portion of temporal bone.
Cavernous sinus blood supply arises from the superior ophthalmic veins, cerebral veins, sphenoparietal
sinuses, deep facial muscles, and inferior ophthalmic veins.
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Drake, et al, Fig 8.44
C.M. Aderman, HMSIII
G. Lieberman, MD
With a better understanding of the orbital
and cavernous sinus anatomy, we can
now form a differential diagnosis for our
patient’s ophthalmoplegia and cranial
nerve findings.
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C.M. Aderman, HMSIII
G. Lieberman, MD
Differential Diagnosis:
Acute Painful Ophthalmoplegia
• Cavernous sinus thrombosis (CN III, IV, VI, V1‐V2, superior ophthalmic vein)
• Orbital apex syndrome (superior orbital fissure: CN III, IV, VI, V1, superior ophthalmic vein; optic canal: ophthalmic artery and optic nerve), our patient did not have impaired vision
• Superior orbital fissure syndrome (CN III, IV, VI, V1), our patient had V2 involvement
• Orbital cellulitis (periorbital swelling, proptosis, chemosis, ophthalmoplegia, fever, decreased vision, pain)
• Preseptal cellulitis (no proptosis or ophthalmoplegia)
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Colson AE, et al, 1999
Ebright JR, et al, 2001
C.M. Aderman, HMSIII
G. Lieberman, MD
Differential Diagnosis:
Chronic Painful Ophthalmoplegia
• Local malignancy, metastasis
• Aseptic thrombus from trauma, myeloproliferative diseases, dehydration
• Granulomatous diseases (TB or fungal, sarcoid, syphilis, Tolosa‐Hunt syndrome)
• Aneurysm of internal carotid artery
• Carotid‐cavernous fistula
• Endocrine exophthalmos
• Ophthalmoplegic migraine
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Colson AE, et al, 1999
Ebright JR, et al, 2001
C.M. Aderman, HMSIII
G. Lieberman, MD
Given that our patient had acute onset of
cranial nerve III, IV, VI, VI and V2
involvement, cavernous sinus
thrombosis is the most likely diagnosis.
Let’s look at the menu of radiologic tests
available for further evaluation.
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C.M. Aderman, HMSIII
G. Lieberman, MD
Cavernous Sinus Thrombosis: Menu of Radiologic Tests
• MRI with and without contrast, MRV
– Sensitive for detection of venous thrombus
• CT with and without contrast
– Usually the first study, may be normal in 30%
• Before CT or MRI were available:
– Clinical diagnosis or found at autopsy
– Cerebral angiography or orbital venography
• Difficult to puncture facial veins with edema
• Also risky to inject contrast under pressure (disseminated infection, extension of thrombus)
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Schuknecht B, et al, 1998
Chu K, et al, 2001
C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Cavernous Sinus Thrombosis on Coronal MRI
Coronal C‐ T1 weighted MRI at the level of the cavernous sinus Thickening of the right cavernous sinus (arrow) compared with the left
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PACS, BIDMC
C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Cavernous Sinus Thrombosis on Axial MRI
Axial C‐ T1 weighted MRI at the level of the orbits Thickening of the right cavernous sinus (arrow)
PACS, BIDMC
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C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Cavernous Sinus Thrombosis on MRA
Three-dimensional time-offlight MR arteriography
Right carotid artery (arrow)
remains patent throughout
its course through the
cavernous sinus
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PACS, BIDMC
C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Cavernous Sinus Thrombosis on Axial CT
The following day
Axial C+ CT at the level of the orbits
Mild enlargement of superior ophthalmic vein (arrow)
Low attenuation region in the right cavernous sinus (arrow) representing thrombus
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PACS, BIDMC
C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Cavernous Sinus Thrombosis on Coronal CT
Coronal C+ CT at the level of the cavernous sinus Areas of low attenuation within the cavernous sinus (arrow) also visible on this view
PACS, BIDMC
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C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Cavernous Sinus Thrombosis, Six Days Later
Six days after presentation
Coronal contrast enhanced T1 weighted MRI with fat suppression at the level of the cavernous sinus Right internal carotid narrowing (arrow) compared with left
Meningeal thickening (arrow) along inferior aspect of temporal lobe consistent with meningitis
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PACS, BIDMC
C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Cavernous Sinus Thrombosis, Twelve Days Later
Twelve days after presentation
Right ICA narrowing (arrows) secondary to inflammatory changes along the wall
MRA
Coronal C+ T1 weighted MRI
PACS, BIDMC
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PACS, BIDMC
C.M. Aderman, HMSIII
G. Lieberman, MD
Our Patient: Cavernous sinus thrombosis, MRA Comparison
Absent flow through the right ICA compared with MRA at presentation (arrows).
On the day of presentation
Twelve days after presentation
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PACS, BIDMC
PACS, BIDMC
C.M. Aderman, HMSIII
G. Lieberman, MD
Cavernous Sinus Thrombosis:
Classic Signs and Symptoms
Fever
Ptosis
Proptosis
Chemosis
Cranial nerve palsies
80-100%
Lethargy
Headache
Periorbital swelling
Papilledema
Venous engorgement
50-80%
Decreased visual acuity
Decreased corneal reflex
Sluggish or dilated pupil Nuchal rigidity
Periorbital sensory loss
< 50%
Diplopia
Seizures
< 20%
Hemiparesis
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Southwick FS, et al 1986
C.M. Aderman, HMSIII
G. Lieberman, MD
Cavernous Sinus Thrombosis:
Pathogenesis
• Dural sinuses are valveless, susceptible to infection from multiple sites (sphenoids and ethmoids most common, also face, tonsils, soft palate, teeth, ears)
• Enlarging infected clots can spread and involve both sides • Can result in sepsis, meningitis, subdural empyema, pituitary necrosis 29
Ebright JR, et al, 2001
C.M. Aderman, HMSIII
G. Lieberman, MD
Our patient: Case Resolution
• Patient ultimately found to have dental infection as source.
• Her course was complicated by septic shock, acute renal failure, DIC, septic pulmonary embolism, and respiratory failure necessitating intubation.
• She eventually stabilized and was discharged on anticoagulation and antibiotics
• Resolution of most cranial nerve symptoms with moderately decreased sensation in V1‐V2
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C.M. Aderman, HMSIII
G. Lieberman, MD
Let’s view some companion cases of
cavernous sinus thrombosis to further
highlight the classic findings on
radiologic imaging.
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C.M. Aderman, HMSIII
G. Lieberman, MD
CST: Companion Case 1
Periorbital swelling, erythema, proptosis, chemosis (conjunctival edema)
Enlarged superior orbital vein (arrows)
Axial (C) and coronal (E) C+ CT
Pavlovich P, et al, 2006
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C.M. Aderman, HMSIII
G. Lieberman, MD
CST: Companion Case 2
Upper lid and periorbital edema, ptosis, chemosis, and conjunctival injection
CT C+ axial slice through orbits
Small collections of gas in both superior ophthalmic veins, the right cavernous sinus and the right upper lid soft tissue (arrows)
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Pavlovich P, et al, 2006
C.M. Aderman, HMSIII
G. Lieberman, MD
CST: Companion Case 3
T1 with contrast showing multiple irregular defects within the enhancing cavernous sinus on the left side (arrowheads). 34
Yoshida T, et al, 2008
C.M. Aderman, HMSIII
G. Lieberman, MD
CST: Companion Case 4
Enhanced axial CT scan showing engorgement of left superior orbital vein with filling defect within it (arrow), with resultant proptosis of the left eye.
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Eustis HS, et al, 1998
C.M. Aderman, HMSIII
G. Lieberman, MD
References
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Chu K, Kang DW, Yoon BW, Roh JK. Diffusion‐weighted magnetic resonance in cerebral venous thrombosis. Arch Neurol. 2001;58(10):1569.
Colson AE, Daily JP. Orbital apex syndrome and cavernous sinus thrombosis due to infection with Staphylococcus aureus and Pseudomonas aeruginosa. Clin Infect Dis. 1999;29(3):701‐702.
Drake RL, Vogl W, Mitchell AWM, eds. Gray’s Anatomy for Students. Philadelphia, PA: Elsevier; 2005.
Ebright JR, Pace MT, Niazi AF. Septic thrombosis of the cavernous sinuses. Arch Intern Med. 2001;161(22):2671‐2676. Eustis HS, Mafee MF, Walton C, Mondonca J. MR imaging and CT of orbital infections and complications in acute rhinosinusitis. Radiologic Clinics of North America. 1998;36(6):1165‐1183. Pavlovich P, Looi A, Rootman J. Septic Thrombosis of the Cavernous Sinus: Two Different Mechanisms. Orbit. 2006;25:39–43.
Schuknecht B, Simmen D, Yüksel C, Valavanis A. Tributary venosinus occlusion and septic cavernous sinus thrombosis: CT and MR findings. AJNR Am J Neuroradiol. 1998;19(4):617‐626. Southwick FS, Richardson EP Jr, Swartz MN. Septic thrombosis of the dural venous sinuses. Medicine (Baltimore). 1986;65(2):82‐106. Yoshida T, Kasai T, Kondo M, et al. Septic cavernous sinus thrombosis caused by penicillin‐resistant Streptococcus. Infections in Medicine. 2008;25(115):20.
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C.M. Aderman, HMSIII
G. Lieberman, MD
Acknowledgments
• Dr. Gillian Lieberman, MD
• Dr. Gul Moonis, MD
• Dr. Rafael Rojas, MD
• Emily Hanson
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