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Cavernous sinus thrombosis

Last reviewed: 13 Nov 2024
Last updated: 16 Apr 2024

Summary

Definition

History and exam

Key diagnostic factors

  • rapid onset of signs and symptoms (acute septic CST)
  • headache
  • fever
  • periorbital edema
  • chemosis and proptosis
  • lateral gaze palsy
  • ophthalmoplegia
  • profound sepsis (acute septic CST)
Full details

Other diagnostic factors

  • ptosis and mydriasis
  • papilledema and/or retinal-vein dilatation
  • decreased corneal reflex
  • hypo- or hyperesthesia 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 or Brudzinski signs
  • seizures
  • loss of visual acuity
Full details

Risk factors

  • recent history of acute sinusitis
  • history of facial infections
  • history of periorbital 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
  • pregnant or postpartum
  • history of malignancy
  • history of recent head or neck surgery
  • vascular abnormalities
  • ulcerative colitis
  • volume depletion
  • heroin overdose
Full details

Diagnostic tests

1st tests to order

  • CBC
  • 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 anticardiolipin antibodies
  • protein S and protein C
  • antithrombin III
  • factor V Leiden
  • hemoglobin electrophoresis
Full details

Tests to consider

  • lumbar puncture with cerebrospinal fluid analysis
Full details

Treatment algorithm

INITIAL

suspected CST

ACUTE

confirmed septic CST: without hemorrhagic complications

confirmed septic CST: with hemorrhagic complications

confirmed aseptic CST: without hemorrhagic complications

confirmed aseptic CST: with hemorrhagic complications

Contributors

Authors

Jayant Pinto, MD

Associate Professor of Surgery

Section of Otolaryngology-Head and Neck Surgery

University of Chicago

IL

Disclosures

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

Cleveland Clinic

Lerner College of Medicine at Case Western Reserve University

Cleveland

OH

Disclosures

MC is a member of the advisory board of Optinose.

Peer reviewers

David Rowed, MD

Division of Neurosurgery

University of Toronto

Toronto

Ontario

Canada

Disclosures

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

Boston

MA

Disclosures

LRC declares that he has no competing interests.

Sorabh Khandelwal, MD

Clinical Associate Professor of Emergency Medicine

Ohio State University

Columbus

OH

Disclosures

SK declares that he has no competing interests.

  • Cavernous sinus thrombosis images
  • Differentials

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

    • ACR appropriateness criteria: cerebrovascular diseases-stroke and stroke-related conditions
    • ACR appropriateness criteria: headache
    More Guidelines
  • Patient information

    Meningitis and septicemia

    Preventing another stroke

    More Patient information
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