Can You Spot Cavernous Sinus Thrombosis?

October 10, 2024

Written by Caitlin Nicholson

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Cavernous sinus thrombosis (CST) is a rare but serious thrombophlebitic disease that can be easy to miss in the emergency department setting. This article provides an overview of CST as well as some pearls for clinching this diagnosis for emergency medicine physicians.

Let’s shed some light in this cave…

Presentation: Consider the diagnosis of CST in patients with recent head or neck infection (most commonly sinusitis or an odontogenic infection) who are now presenting with a frontal headache and systemic symptoms such as fever or chills. Most patients will also experience ocular symptoms such as eyelid swelling, photophobia, pain with extraocular movement, or changes to their vision.

ED Evaluation: Diagnosis can be confirmed via CT imaging of the orbits and head with delayed IV contrast or magnetic resonance venography (MRV). Laboratory workup should include inflammatory markers and blood cultures. Consider lumbar puncture in patients with concern for meningitis or encephalopathy.

ED Management: Broad spectrum antibiotics that cover both gram negative and anaerobic bacteria should be promptly administered for patients where this diagnosis is suspected. Some patients will also require treatment with anticoagulation. Consultation with otolaryngology, ophthalmology and possibly neurosurgery is recommended as some patients will require surgical drainage.

How will this change my practice?
CST is an especially tricky diagnosis to make in the emergency department as these patients often present like many of our other undifferentiated septic patients. After reading this article, I will have heightened suspicion for CST in patients with ocular symptoms or who report symptoms consistent with a head/neck infection within the last month. Interestingly, a CT head without contrast is often unremarkable, which makes me think I should consider a CT with orbits and head with contrast a little more often, especially since laboratory findings may be indeterminate. 

Source
High risk and low prevalence diseases: Cavernous sinus thrombosis. Am J Emerg Med. 2024;83:47-53. doi:10.1016/j.ajem.2024.06.024.
PMID: 38959601.