What are the symptoms of cavernous sinus thrombosis?

Symptoms of Cavernous Sinus Thrombosis

Cavernous sinus thrombosis (CST) presents with a characteristic constellation of symptoms including fever, headache, and ocular manifestations such as chemosis, periorbital edema, ptosis, ophthalmoplegia, and vision changes, with cranial nerve VI palsy being the most common neurological finding. 1

Key Clinical Manifestations

Ocular Symptoms (Most Characteristic)

• Periorbital edema - often unilateral initially, may progress to bilateral involvement
• Chemosis (conjunctival edema)
• Proptosis (protrusion of the eyeball)
• Ptosis (drooping of the upper eyelid)
• Ophthalmoplegia (impaired eye movement)
• Visual disturbances - may progress to blindness if untreated 2

Cranial Nerve Involvement

• Cranial nerve VI (abducens) - most commonly affected, causing lateral rectus palsy and inability to abduct the eye 1
• Cranial nerve III (oculomotor) - causing ptosis and limitation of eye movement
• Cranial nerve IV (trochlear) - affecting downward gaze
• Cranial nerve V (trigeminal) - causing facial sensory changes, particularly in V1 and V2 distributions 1

Systemic Symptoms

• Fever - often high-grade
• Headache - typically severe and progressive
• Altered mental status - ranging from confusion to somnolence 3
• Seizures - occur in approximately 40% of patients 3

Clinical Progression

The symptoms of CST typically evolve in a characteristic pattern:

1. Initial phase (1-2 days):

   • Unilateral periorbital edema
   • Headache
   • Fever

2. Progressive phase (2-4 days):

   • Bilateral involvement (as thrombosis extends to the contralateral cavernous sinus)
   • Worsening ocular symptoms
   • Development of cranial nerve palsies

3. Advanced phase (if untreated):

   • Altered mental status
   • Seizures
   • Neurological deterioration

Special Considerations

• Symptom onset pattern: CST often presents with slowly progressive symptoms. In the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT), symptom onset was acute (<48 hours) in 37% of patients, subacute (>48 hours to 30 days) in 56% of patients, and chronic (>30 days) in 7% of patients 3

• Diagnostic delays: The median delay from symptom onset to hospital admission was 4 days, and from symptom onset to diagnosis was 7 days 3

• Atypical presentations: Elderly patients or those with deep venous system involvement may present with somnolence or confusion without obvious focal neurological deficits, which can be easily overlooked 4

Complications

• Venous infarction - may be hemorrhagic in 40% of cases 3
• Increased intracranial pressure
• Meningitis
• Sepsis
• Adult respiratory distress syndrome in severe cases 2

Common Etiologies

The most common underlying causes of CST include:

• Sinusitis (especially sphenoid and ethmoid)
• Facial infections
• Dental infections
• Trauma or surgery to the face or head
• Thrombophilia
• Dehydration

Common causative organisms include Staphylococcus aureus, Streptococcal species, oral anaerobes, and Gram-negative bacilli 1.

Diagnostic Approach

When CST is suspected based on clinical presentation:

1. Imaging: Contrast-enhanced MRI with MR venography is the gold standard, with CT venography as an acceptable alternative when MRI is unavailable 4

2. Laboratory testing: Typically reveals elevated inflammatory markers; blood cultures are positive in up to 70% of cases 1

Early recognition of these symptoms is critical, as prompt diagnosis and treatment significantly reduce morbidity and mortality in patients with cavernous sinus thrombosis 4, 1.