Cavernous sinus thrombosis

Last reviewed: 5 Jan 2023
Last updated: 13 Nov 2019



History and exam

Key diagnostic factors

  • presence of risk factors
  • rapid onset of signs and symptoms (acute septic CST)
  • headache
  • fever
  • peri-orbital oedema
  • chemosis and proptosis
  • lateral gaze palsy
  • ophthalmoplegia
  • profound sepsis (acute septic CST)
More key diagnostic factors

Other diagnostic factors

  • ptosis and mydriasis
  • papilloedema and/or retinal-vein dilatation
  • decreased corneal reflex
  • hypo- or hyper-aesthesia in the distribution of the ophthalmic and maxillary nerves
  • mental state changes (e.g., confusion, drowsiness, coma)
  • clinically detectable primary infection site
  • meningismus (nuchal rigidity, photophobia, and headache)
  • positive Kernig's or Brudzinski's signs
  • seizures
  • loss of visual acuity
Other diagnostic factors

Risk factors

  • recent history of acute sinusitis
  • history of facial infections
  • history of peri-orbital infection
  • history of otitis media, mastoiditis, or petrositis
  • history of dental or oral infection
  • history of sepsis
  • immunosuppression
  • genetic prothrombotic condition
  • acquired and other prothrombotic states
  • history of head and neck trauma
  • use of oral contraceptives
  • history of malignancy
  • history of recent head or neck surgery
  • vascular abnormalities
  • ulcerative colitis
  • volume depletion
  • heroin overdose
More risk factors

Diagnostic investigations

1st investigations to order

  • FBC
  • contrast-enhanced high-resolution CT of head
  • contrast-enhanced MRI of head
  • blood culture
  • microscopy and culture of suppurative fluid or tissue from primary infective source
  • antiphospholid and anticardiolipid antibodies
  • protein S and protein C
  • antithrombin III
  • factor V Leiden
  • haemoglobin electrophoresis
More 1st investigations to order

Investigations to consider

  • LP with CSF analysis
More investigations to consider

Treatment algorithm


suspected CST


confirmed septic CST: without haemorrhagic complications

confirmed septic CST: with haemorrhagic complications

confirmed aseptic CST: without haemorrhagic complications

confirmed aseptic CST: with haemorrhagic complications



Jayant Pinto, MD

Associate Professor of Surgery

Section of Otolaryngology-Head and Neck Surgery

University of Chicago



JP serves as a speaker and advisor to Optinose and Stallergenes. JP is a member of the advisory board for Genentech and ALK. JP has received grants from the National Institutes of Health.

Mohamad R. Chaaban, MD, MSCR, MBA

Associate Professor

Department of Otolaryngology

University of Texas Medical Branch



MC declares that he has no competing interests.

Peer reviewers

David Rowed, MD

Division of Neurosurgery

University of Toronto





DR declares that he has no competing interests.

Louis R. Caplan, MD

Lecturer in Neurology

Hospital Chief

Cerebrovascular/Stroke Division

Beth Israel Deaconess Medical Center

Division of Cerebrovascular/Stroke




LRC declares that he has no competing interests.

Sorabh Khandelwal, MD

Clinical Associate Professor of Emergency Medicine

Ohio State University




SK declares that he has no competing interests.

  • Cavernous sinus thrombosis images
  • Differentials

    • Peri-orbital or orbital cellulitis
    • Superior orbital fissure syndrome
    • Orbital apex syndrome
    More Differentials
  • Guidelines

    • ACR appropriateness criteria: headache
    • ACR appropriateness criteria: orbits, vision and visual loss
    More Guidelines
  • Patient leaflets

    Meningitis and septicaemia

    Preventing another stroke

    More Patient leaflets
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