A 15 year old female with no pmh presents to the ED with 1 week of slow onset frontal headache, now complains of 2 days of blurry vision. Pt has had a URI with a sore throat and sinus congestion x 2 weeks. On exam patient has bilateral lid swelling, sluggish pupils, EOMI, and otherwise non-focal neuro exam.
What is the preferred diagnostic test for this patient:
- Lumbar Puncture
- CT non contrast
- MRI non contrast
- MR Venogram
- Carotid Angiography
4. MRV or MR venogram
The patient needs to be evaluated for cavernous sinus thrombosis. The cavernous sinus is the most centrally located sinuses and surrounds the sella tursica and is just posterior to the optic chiasm. This sinus drains the facial veins, as well as the sphenoid and the middle cerebral veins. There are no valves so flow is dependent on pressure gradient and is possible to have reverse flow. The internal carotid artery, CN III, IV,VI, and V1 and V2 branches and Cavernous sinus thrombosis is a rare form of cerebral thrombosis. The most commonly is a late complication of a paranasal or sinus infection. Other common causes are trauma and systemic bacterial illness. If infectious 70% of the cases are secondary to Staph Aureus, and other lesser causes are Strep Pneumo, gram negatives, anaerobes, and fungi. This can also be rarely caused by hypercoaguable states such as, cancer, SLE, pregnancy, etc.
Usually has a 1-2 week latency period then presents with:
- HA- 50-90% of cases
- Chemosis, proptosis, periobital edema- as progresses up to 90%
- Visual impairment- 7-22%
MR venogram showing thrombosis is test of choice, CT venogram is also a possibility. Venous bulging can be seen on non contrast CT
This disease can progress quickly and cause high morbidity (vision loss, paralysis of ocular muscles) and mortality. Can progress to meningitis, abscess, encephalitis, epidural/subdural empyemas, exention of thrombosis leading to infarction and CVA. It is important to treat quickly with antibiotics, preferably a penicillinase resistant PCN and a 3rd or 4th generation cephalosporin (treat for 3-4 weeks), and possibly to the OR for I&D of primary infection, I&D of cavernous sinus has not been proven to be effective.
Desa, V;Green, R. Cavernous Sinus Thrombosis: Current Therapy
Journal of Oral and Maxillofacial Surgery. Vol 70-9. Pages 2085- 2091