What are the typical presentations of cavernous sinus thrombosis?

Typical Presentation of Cavernous Sinus Thrombosis

Cavernous sinus thrombosis (CST) typically presents with fever, headache, and ocular manifestations including chemosis, periorbital edema, ptosis, ophthalmoplegia, and vision changes, with bilateral involvement often developing within days of initial unilateral symptoms. 1

Key Clinical Features

Cardinal Symptoms and Signs

• Headache: Present in the vast majority of cases
• Fever: Almost universally present in septic CST
• Ocular manifestations:
  • Periorbital edema
  • Chemosis (conjunctival swelling)
  • Proptosis (bulging of the eye)
  • Ptosis (drooping eyelid)
  • Limited extraocular movements
  • Visual impairment

Cranial Nerve Involvement

• Cranial nerve VI (abducens): Most commonly affected, resulting in lateral rectus palsy and limited lateral gaze 1
• Other cranial nerves: III, IV, and V may also be affected due to their anatomical course through the cavernous sinus 2
• Ophthalmoplegia: Restriction of eye movements, particularly lateral gaze

Progression Pattern

• Initial unilateral involvement: Symptoms typically begin in one eye
• Bilateral progression: Involvement of the opposite eye commonly occurs within 24-48 hours of initial symptoms 3
• Rapid deterioration: Can progress quickly to severe neurological compromise

Underlying Causes and Risk Factors

Infectious Sources

• Sinusitis: Most common cause, particularly sphenoid and ethmoid sinusitis 2, 4
• Facial infections: Including furuncles in the danger triangle of the face
• Dental abscesses: Can spread through valveless facial veins
• Otitis media: Less common source of infection

Common Pathogens

• Staphylococcus aureus: Most frequent bacterial cause
• Streptococcal species
• Oral anaerobes
• Gram-negative bacilli 1

Diagnostic Considerations

Laboratory Findings

• Elevated inflammatory markers (ESR, CRP)
• Leukocytosis
• Positive blood cultures in up to 70% of cases 1
• CSF abnormalities if meningeal involvement

Imaging

• MRI with MRV: Gold standard with highest sensitivity 5
• CT with contrast: Recommended in emergency settings, may show:
  • Cavernous sinus filling defects
  • Orbital edema
  • Sinus opacification
  • Associated parenchymal changes 5, 1

Complications

Neurological Complications

• Meningitis
• Cerebral infarction
• Brain abscess
• Subdural empyema
• Intracerebral hemorrhage 6
• Aneurysmal subarachnoid hemorrhage (rare) 7

Systemic Complications

• Sepsis
• Multiorgan failure
• Death (mortality rate around 30% despite treatment) 3

Clinical Pitfalls and Diagnostic Challenges

Delayed Diagnosis

• Symptoms may initially mimic less serious conditions
• Median delay from symptom onset to diagnosis can be up to 7 days 5
• Initial CT scans may be normal in up to 30% of cases 5

Atypical Presentations

• Isolated headache without obvious ocular signs (early stage)
• Mental status changes without focal neurological deficits
• Presentation resembling idiopathic intracranial hypertension 2

Key Distinguishing Features

The combination of:

1. Recent history of sinusitis, facial infection, or dental procedure
2. Acute onset of severe headache
3. Ocular signs (especially ophthalmoplegia)
4. Rapid progression to bilateral involvement
5. Fever and systemic toxicity

This constellation strongly suggests cavernous sinus thrombosis and should prompt immediate imaging and treatment to prevent the high morbidity and mortality associated with this condition.