Septic Cavernous Sinus Thrombosis

Today, we discussed a case of a young patient who presented with acute onset headache and right sided V2 paresthesia, eventually found to have septic cavernous sinus thrombosis.

A few learning points:

1) Early clinical manifestations of septic cavernous sinus thrombosis are non-specific, but include:

  • headache (most common!)
  • focal neurological symptoms including diplopia or hypo/hyperesthesia in the ophthalmic (V1) and maxillary (V2)
  • orbital signs including chemosis, peri-orbital edema, exophthalmos

This is often misdiagnosed as a migraine. Any headache associated with the presence of a cranial nerve deficit should raise your concern!

PEARL: Facial infections involving the "danger zone" pictured below can potentially lead to septic cavernous sinus thrombosis as the venous system of this area drains directly into the cavernous sinuses.

2) Diagnosis is clinical, but the following can be helpful:

  • leukocytosis
  • positive blood cultures
  • CSF with lymphocytic pleocytosis, elevated protein, normal glucose
  • imaging (MRI/MRV) consistent with cavernous thrombosis

3) Key to treatment is early IV antibiotics with staph coverage. An older case series suggested improved mortality with anticoagulation, though more recent data is limited.
(Southwick FS, Richardson EP, Swartz MN. Septic thrombosis of the venous dural sinuses. Medicine (Baltimore). 1986;6582-106)