From the Guidelines
Cavernous Sinus Thrombosis (CST) typically presents with signs and symptoms related to increased intracranial pressure and focal brain injury, including headache, papilledema, and diplopia.
Common Signs and Symptoms
- Headache, often described as diffuse and progressive in severity over days to weeks 1
- Papilledema, indicative of increased intracranial pressure 1
- Diplopia, caused by sixth nerve palsy 1
- Focal neurological signs, such as hemiparesis and aphasia, due to venous ischemia or hemorrhage 1
- Seizures, occurring in approximately 40% of patients 1
- Psychosis, in conjunction with focal neurological signs 1
- Bilateral brain involvement, including bilateral thalamic involvement and alterations in level of consciousness 1
Imaging Findings
- MRI is the preferred imaging modality for diagnosing CST, with findings including absence of a flow void, alteration of signal intensity in the dural sinus, and a "hyperintense vein sign" 1
- CT may also be used, particularly in cases where MRI is not readily available, with findings including the "empty delta sign" 1
Clinical Considerations
- CST is an important diagnostic consideration in patients with headache, papilledema, and diplopia, even in the absence of other neurological focal signs 1
- Anticoagulation is the principal therapy for CST, aimed at preventing thrombus propagation and increasing recanalization 1
- The presence of intracranial hemorrhage is not a contraindication to anticoagulation, but necessitates serial assessment for hematoma development and/or expansion 1
From the Research
Signs and Symptoms of Cavernous Sinus Thrombosis (CST)
The signs and symptoms of CST can be varied and nonspecific, making diagnosis challenging. Some common presenting signs and symptoms include:
- Fever
- Headache
- Ocular manifestations, such as:
- Chemosis
- Periorbital edema
- Ptosis
- Ophthalmoplegia
- Vision changes
- Cranial nerve palsies, particularly:
- Cranial nerve VI (resulting in lateral rectus palsy)
- Cranial nerves III, IV, and V may also be affected
- Severe headache and fever can also be presenting symptoms, as seen in cases of contralateral CST caused by sphenoid sinusitis 2
- The onset of symptoms can be acute and fulminant or indolent and delayed, and the clinical presentation can range from subtle to severe 3
Clinical Presentation
The clinical presentation of CST can be highly variable, and the disease may affect the pulmonary and central nervous systems 4. The diagnosis is challenging and requires clinical suspicion and confirmation by imaging. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases 4.
Diagnostic Considerations
Imaging studies, such as computed tomography of the head and orbits with intravenous contrast delayed phase imaging, or magnetic resonance venography, can help establish the diagnosis of CST 4, 2, 3. A high index of suspicion is necessary to diagnose CST, especially in cases with atypical presentations or when cranial nerve palsies persist 3.
Underlying Etiologies
The most common underlying etiologies of CST include sinusitis or other facial infection, maxillofacial trauma or surgery, thrombophilia, dehydration, or medications 4. The most frequent bacterial etiologies are Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli 4.