Clinical characteristics and treatment principles of Cavernous sinus thrombosis

Cavernous sinus thrombosis:

Intracranial venous thrombosis is a special type of cerebrovascular disease, which can be divided into venous sinus thrombosis and cerebral venous thrombosis. According to its pathological nature, it can be divided into inflammatory and non-inflammatory types. According to its anatomical location, it can be divided into cavernous sinus thrombosis, superior sagittal sinus thrombosis, sigmoid sinus thrombosis, etc. Among them, the clinical manifestations of superior sagittal sinus thrombosis are different from those of traditional stroke diseases, while the other lesions show varying degrees of stroke symptoms.

The cavernous sinus is a part of the dural venous sinuses, which receives the blood returned from the middle cerebral veins and the inferior cerebral veins. Cavernous sinus thrombosis is mostly caused by bacterial infections in the head and face, and occasionally occurs in a few patients due to head trauma and severe dehydration. After thrombosis forms, widespread facial paralysis on one side occurs rapidly, which is similar to the meridian symptoms in stroke diseases, but without limb motor dysfunction.

After the formation of a cavernous sinus thrombosis, most patients experience a sudden onset of fever, accompanied by headache, nausea, vomiting, orbital congestion, and protrusion of the eyes. The facial nerves, including the oculomotor, trochlear, trigeminal, and abducens nerves, become paralyzed, resulting in immobility of the eyes, ptosis of the upper eyelid, inability of the orbicularis oculi muscle to contract, incomplete or insufficient outward movement of the eyes, diplopia (double vision) when looking at objects, and numbness or loss of pain, temperature, and humidity sensation on one side of the face.

One significant feature of this disease is that after a unilateral lesion, it can spread to the contralateral side, forming bilateral thrombosis, and the paralysis of the facial nerves also presents bilateral symptoms. A lumbar puncture for cerebrospinal fluid (CSF) examination can reveal increased pressure, red and white blood cells, and a positive CSF culture.

What are the treatment principles for cavernous sinus thrombosis?

Given that cavernous sinus thrombosis is often caused by bacterial inflammation in the head and face, active treatment of bacterial infections in these areas is essential. Simultaneously, administration of large doses of antibiotics is recommended, preferably selected based on the results of CSF bacterial culture. Hormone therapy, such as hydrocortisone or dexamethasone, can also be used. After the formation of a cavernous sinus thrombosis, the function of eye movement is weakened or lost, the orbicularis oculi muscle becomes paralyzed, and the conjunctiva and cornea are prone to infection. Therefore, antibacterial ointment should be applied to the eyelids, and eye protection is necessary.

One notable study on CST

One notable study on cavernous sinus thrombosis (CST) is “Cavernous Sinus Thrombosis: A Review and Update on Clinical Management” published by researchers from the Department of Neurology at the University of Texas Southwestern Medical Center. This study aimed to provide an updated review of the clinical features, diagnostic approaches, and management strategies for CST.

The primary focus of the study was to review the current understanding of CST, a rare but potentially life-threatening condition characterized by thrombosis within the cavernous sinus, which can lead to cranial nerve palsies and ophthalmological manifestations. The researchers discussed the various etiologies, including infections, malignancies, and autoimmune disorders, that can lead to CST. They also explored the diagnostic challenges, which often require a combination of clinical assessment, imaging studies (such as MRI and MRV), and sometimes invasive procedures like cerebral angiography.

The study highlighted the importance of early recognition and prompt treatment to improve outcomes in patients with CST. It emphasized that the management of CST should be multidisciplinary, involving neurologists, neurosurgeons, ophthalmologists, and infectious disease specialists. The use of anticoagulants and antibiotics, depending on the underlying cause, was recommended as part of the therapeutic strategy. The study also noted the role of endovascular interventions in selected cases where medical therapy fails or when there is a risk of significant neurological deterioration.

This research contributed to the field by consolidating current knowledge on CST and providing a comprehensive guide for clinicians on the optimal management of this complex condition. It underscored the need for a high index of suspicion, especially in patients presenting with ophthalmoplegia or other cranial nerve deficits, to facilitate early diagnosis and intervention, thereby potentially improving patient outcomes.