Cavernous Sinus Thrombosis Workup

  • Author: Rahul Sharma, MD, MBA, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Oct 25, 2011
 

Laboratory Studies

  • Cavernous sinus thrombosis (CST) is a clinical diagnosis and lab studies are seldom specific. Most patients exhibit a polymorphonuclear leukocytosis, often marked with a shift toward immature forms. Examination of the cerebrospinal fluid is consistent with either a parameningeal inflammation or frank meningitis. Blood culture results generally are positive for the offending organism.
  • One study by Misra et al showed that a D-dimer may be useful in patients with suspected cortical sinus venous thrombosis (CSVT).[4]
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Imaging Studies

  • Historically, a number of techniques have been used to image CST, including plain sinus radiography, carotid angiography, and orbital venography. In current practice, computed tomography (CT) scan or magnetic resonance imaging (MRI) with contrast is the modality of choice to confirm the diagnosis of CST and to differentiate it from alternatives such as orbital cellulitis, which may have a similar clinical presentation.
  • MRI with MR venogram (MRV) is the preferred imaging choice as the MRV will show the absence of venous flow in the affected cavernous sinus.
  • On noncontrast CT, thrombosis of the cavernous sinus can be appreciated as increased density. The introduction of intravenous contrast can reveal filling defects within the cavernous sinus as well as thickening of the superior ophthalmic vein. Nevertheless, CT scan findings may be subtle, and a negative CT scan cannot rule out CST reliably when the clinical suspicion is high.
  • Carotid angiography can demonstrate narrowing or obstruction of the intercavernous segment of the carotid artery. MRI and CT scan can also show this narrowing and/or obstruction of the carotid artery.
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Procedures

  • Lumbar puncture may be helpful in distinguishing CST from more localized processes (eg, sinusitis, orbital cellulitis). Lumbar puncture reveals inflammatory cells in approximately 75% of cases.
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Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Rahul Sharma, MD, MBA, FACEP  Assistant Professor, Weill Medical College of Cornell University; Assistant Director for Operations, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center

Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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  2. Seow VK, Chong CF, Wang TL, Lin CM, Lin IY. Cavernous sinus thrombophlebitis masquerading as ischaemic stroke: a catastrophic pitfall in any emergency department. Emerg Med J. Jun 2007;24(6):440. [Medline].

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  4. Misra UK, Kalita J, Bansal V. D-dimer is useful in the diagnosis of cortical venous sinus thrombosis. Neurol India. Jan-Feb 2009;57(1):50-4. [Medline].

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  22. Zimmer J, Bhatt J, et al. Is it all in his head?. The Internet Journal of Pediatrics and Neonatology. 2006;6.

 
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Anatomy of cross section of cavernous sinus showing close proximity to cranial nerves and sphenoid sinus.
 
 
 
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