Magnetic resonance imaging mri with and without contrast and magnetic resonance venography mrv are the gold standard for diagnosis of cerebral venous sinus thrombosis that allow for direct. Postcontrast scans show absent blood flow in the left superior ophthalmic vein due to its thrombosis and dural thickening within left cavernous sinus caused by inflammation. Cavernous sinus thrombosis is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by nasal furuncles or bacterial sinusitis. Localized thrombosis is the most common type of thrombosis and has been documented throughout the body including cerebral, retinal, upper and lower extremity, and abdominal veins. Cavernous sinus thrombosis statpearls ncbi bookshelf. Recently, some studies have highlighted the value of t2weighted gradientecho mri t2wi in the diagnosis of cvt.
Cavernous sinus thrombosis is generally a fulminant process with high rates of. Examination revealed him to be irritable but with a glasgow coma score of 1515. Cavernous sinus thrombosis eye disorders merck manuals. In particular, chronic thrombosis of dural venous sinus may resemble a true chameleon on standard mr and mrv neuroimaging, because organized thrombus enhances mimicking a patent venous sinus on longacquisition contrastenhanced mrv sequences and tof mrv may disclose ambiguous findings related to venous sinus asymmetry or retrograde flow. Cerebral venous sinus thrombosis cvst is an uncommon condition that is becoming more frequently recognized with the availability of mri. Cerebral vein and dural sinus thrombosis intechopen. Ct revealed bilateral thalamic infarcts and incomplete sinus thrombosis. We sought to more fully characterize the imaging findings of this entity on mr imaging, timeofflight mr venography tofmrv, and elliptic centricordered contrastenhanced mr venography cemrv. Clinically patients with cerebral venous thrombosis present with variable symptoms ranging from headache to seizure and coma in severe cases. Cavernous sinus trombosis dr munish kumar g b pant delhi 2. The dural sinuses are grouped into the sagittal, lateral including the transverse, sigmoid, and petrosal sinuses, and cavernous sinuses. Delay in diagnosis of cerebral venous and sinus thrombosis.
Original article from the new england journal of medicine bilateral cavernous sinus thrombosis. Ct and highfield mri in septic thrombosis of the cavernous. Cavernous sinus thrombophlebitis postgraduate medical. This usually develops as a sharp pain located behind or around the eyes that steadily gets worse over time. Looking for sinus intercavernosi anterior et posterior. Imaging lesions of the cavernous sinus american journal of. It can be preceeded in pregnant women, children, and patients with renal failure limits of ct. Mri, however, is better at detecting dural venous sinus thromboses 1,16.
As such, please refer to the cerebral venous thrombosis article for a general discussion. To show imaging findings of cerebral venous thrombosis and to highlight possible pitfalls. Cerebral venous thrombosis is a rare entity in pregnancy and the postpartum period, with an incidence of 1. Mri handbook mr physics, patient positioning, and protocols. Contemporary brain imaging techniques angiography, magnetic resonance imaging mri and magnetic resonance angiography mra allow the diagnosis of. The intracavernous internal carotid artery with its periarterial sympathetic plexus runs between the venules of the parasellar venous plexus fig. In older children it is often local infection, such as mastoiditis, or coagulopathy.
On ct, various direct and indirect findings of cst may be. Enlargement of the left cavernous sinus is seen on precontrast t1 coronals. Cavernous sinus thrombosis investigations bmj best. Angiography confirmed thrombosis of the straight sinus and vein of galen. Challenging presentations of cavernous sinus thrombophlebitis. Of these patients, 11 consecutive patients all women. Ahmed al jishi, department of surgery, division of neurosurgery, mcmaster. Cavernous sinus thrombosis symptoms, diagnosis and. Early recognition of cavernous sinus thrombosis which, often presents with. Large venous space situated in the middle cranial fossa, on either side of body of the sphenoid bone.
Sudden onset proptosis secondary to cavernous sinus thrombosis from underlying mandibular dental infection. The signs and symptoms are extremely varied and nonspecific, being the diagnosis made through magnetic resonance imaging mri. Brain imaging with mri and ct presents over 180 disease processes and normal variants, grouping entities by these basic patterns to accentuate differential diagnostic. Cerebral venous sinus thrombosis is an uncommon condition thought to affect approximately five people per million annually. Image from a ctv demonstrating a filling defect in the sss anteriorly and posteriorly, representing thrombus. Cavernous sinus anatomy large venous space situated in the middle cranial fossa, on either side of body of the sphenoid bone. Cavernous sinus thrombosis cst was initially described by bright in 1831 as a complication of epidural and subdural infections. Cerebral venous and sinus thrombosis is a relatively rare condition with a variable presentation that can translate into a difficult workup and a delay in diagnosis and treatment.
This is a rare disorder and can be of two typesseptic cavernous thrombosis and aseptic cavernous thrombosis. Cavernous sinus thrombosis is generally a fulminant process with high rates of morbidity and mortality. Intracerebral hemorrhage is a wellknown complication of cvt, seing also the cause of his death. Transverse sinus thrombosis may be oligosymptomatic, presenting only with single or multiple cranial nerve lesions, which almost always initially lead to another. Acr appropriateness criteria cerebrovascular disease. Management of inadvertent injury to superior sagittal. We describe the successful use of mechanical thrombectomy and thrombolysis in the case of an eighteenyearold woman that presented with progressive thrombosis of the jugular veins and dural sinuses despite adequate.
The cavernous sinus is a relatively large venous channel formed by a splitting of the dura mater on each side of the body of the sphenoid bone. Mr angiography mra and venography mrv were also within normal limits. The use of anticoagulation in patients with cavernous sinus thrombosis who have associated intracerebral hemorrhage secondary approach to the pediatric patient with vision change view in chinese conditions that predispose to specific types of vision change include thrombotic disorders cavernous sinus thrombosis, branch retinal artery. Because of its complex neurovascular anatomic relationship, cavernous sinus thrombosis is the most important of any intracranial septic thrombosis. They found that 56% of patients had isolated pe without any peripheral thrombus. Thrombophlebitis of the cavernous sinus potentially is a lethal condition usually caused by bacterial or fungal invasion complicating sinusitis in patients with poorly controlled diabetes or immunosuppression. Other causes include bacteremia, trauma, and infections of the ear or maxillary teeth. The most common are neurogenic tumors and cavernoma. In neonates shock and dehydration is a common cause of venous thrombosis.
Most commonly the form is of septic cavernous sinus thrombosis. However, in real life clinical practice, radiologists usually make their differential diagnoses according to the image patterns, as the etiology is often unknown. The most common initial symptom of cavernous sinus thrombosis is a headache. From april 2007 to august 2009, patients with suspected or known cerebral venous and sinus thrombosis referred for ce mri were examined prospectively by tof mrv, ce mrv and mprage sequences. Cavernous sinus thrombosis cst is a rare condition, defined as a septic thrombophlebitis of the cavernous sinus.
The venous connections of the cavernous sinus are illustrated in figure 3. Infection can spread to the cavernous sinus either as an extension of thrombophlebitis or by septic emboli. Mri with contrast is the imaging modality of choice to confirm its presence and to differentiate it from alternatives such as orbital cellulitis, which may have a similar clinical presentation. Sagittal ct scan of the head demonstrating an enlarged, tubular right superior ophthalmic vein jones rg, arnold b. Tumors of the nasopharynx, skull base, and sphenoid sinus may extend to the cs as can perineural and hematogenous metastases. New guidelines released for cerebral venous thrombosis. Diagnostic performance of mri sequences for evaluation of dural venous sinus thrombosis. Thrombus formation within the cavernous sinus, which may be either septic or aseptic in origin. Diagnostic performance of mri sequences for evaluation of dural.
Pdf neuroimaging of cerebral venous sinus thrombosis. Cerebral venous thrombosis cvt is an uncommon cause of stroke with diverse etiologies and varied clinical presentations. Cavernous sinus thrombosis is usually a late complication of an infection of the central face or paranasal sinuses. Not absolutely sensitive or specific for the diagnosis of cst. Department of surgery, mcmaster university, canada corresponding author. The authors present a 75yearold woman, admitted in the emergency room. The sinus communicates directly with the veins of the orbit, so arterial pressure can be transmitted to the ophthalmic veins, which may become pulsatile. The cavernous sinus extends from the medial end of the superior orbital fissure to the petrous portion of the temporal bone. It can be classified as septic or aseptic, depending on its aetiology. Cavernous sinus thrombosis radiology reference article.
Cavernous sinus thrombosis cst is a rare, lifethreatening disorder that can. Cavernous sinus thrombosis cst is a rare, lifethreatening disorder that can complicate facial infection, sinusitis, orbital cellulitis, pharyngitis, or otitis or following traumatic injury or surgery, especially in the setting of a thrombophilic disorder. Cavernous sinus definition of cavernous sinus by medical. Cavernous sinus thrombosis cst is the formation of thrombus clot within the cavernous sinus, which can either be septic or aseptic. Imaging of cerebral venous thrombosis, pearls and pitfalls epos. Dec 07, 2014 because of its complex neurovascular anatomic relationship, cavernous sinus thrombosis is the most important of any intracranial septic thrombosis. Partially recanalized chronic dural sinus thrombosis. Ppt cavernous sinus thrombosis human head and neck. The following day, brain and brain stem magnetic resonance imaging mri was unimpressive, demonstrating normal enhancement of the cavernous sinus without evidence of thrombosis. Mri findings of elevated intracranial pressure in cerebral. Imaging lesions of the cavernous sinus american journal.
Sixteen 52% of the cvt patients had simultaneous involvement of multiple sinuses. The foci of haemorrhage in the right frontal parenchyma are typical of those seen with sinus thrombosis. Cavernous sinus thrombosis is a clinical diagnosis. Most patients have thrombosis in more than one area of the cerebral drainage system.
This book is distributed under the terms of the creative commons. Dural venous sinus thrombosis radiology reference article. Bilateral cavernous sinus thrombosis complicating sinusitis. Cavernous sinus thrombosis is a rare yet potentially fatal and debilitating condition in children which is important to diagnose early. Management of inadvertent injury to superior sagittal sinus in parasagittal meningioma. Ppt cavernous sinus thrombosis human head and neck human. Magnetic resonance venogram mrv revealed a right internal jugular and sigmoid sinus thrombosis. We describe the successful use of mechanical thrombectomy and thrombolysis in the case of an eighteenyearold woman that presented with progressive thrombosis of the jugular veins and dural sinuses.
Jul 16, 2018 cavernous sinus thrombosis cst was initially described by bright in 1831 as a complication of epidural and subdural infections. Management of inadvertent injury to superior sagittal sinus. Interior is divided into a number of spaces or caverns by trabeculae cavernous sinus anatomy boundaries anterior extends into medial end of. The origin of aseptic cavernous sinus thrombosis is usually through trauma or a prothrombotic.
Tumors of the nasopharynx, skull base, and sphenoid sinus may extend to the cs as can perineural and hematogenous. Magnetic resonance imaging mri of the brain demonstrated findings consistent with meningitis, a small rightsided subdural empyema and partial thrombosis of bilateral superior ophthalmic veins and cavernous sinus. Cavernous sinus thrombosis cst is a rare condition, usually results from a late complication of an infection of the paranasal sinuses. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Most imaging books are ordered according to underlying etiology. It requires a high index of suspicion and confirmation by imaging. Figure caption and citation for the preceding image starts.
In a patient with septic thrombosis of the cavernous sinuses ct demonstrated multiple filling defects due to clot formation, but 1. Cerebral venous thrombosis venous sinus thrombosis is caused by clots in the dural venous sinuses and accounts for 0. Feb 25, 2018 cerebral venous thrombosis venous sinus thrombosis is caused by clots in the dural venous sinuses and accounts for 0. Symptoms and signs include pain, proptosis, ophthalmoplegia, vision loss, papilledema, and fever. The abducens nerve runs lateral to the internal carotid artery, but medial to the oculomotor and trochlear nerves and the ophthalmic. Vascular and parameningeal infections of the head and neck. Cerebral venous thrombosis the radiology assistant. Sinus intercavernosi anterior et posterior article about. Al jishi a, yarascavitch b, murty n 2014 management of inadvertent injury to superior sagittal sinus in parasagittal meningioma. Cavernous sinus thrombosis cst is a rare condition, with few cases described in the literature. Pre and postcontrast brain mri cavernous sinus protocol indications. The incidence of cerebral venous thrombosis during pregnancy and post partum ranges from 1 in 2500 deliveries to 1 in 10,000 deliveries in. The abducens nerve courses in the lateral venous space 2.
Dural venous sinus thrombosis is a subset of cerebral venous thrombosis, often coexisting with cortical or deep vein thrombosis, and presenting in similar. Find out information about sinus intercavernosi anterior et posterior. Dwi shows a small acute infarction in the right flocculus. Cavernous sinus thrombosis investigations bmj best practice.
Acr appropriateness criteria cerebrovascular disease evidence. The cavernous sinuses consist of extradural venous plexuses surrounded by a dural fold. In our center, protocol for cerebral venous thrombosis diagnosis is. A carotid cavernous sinus fistula is an abnormal communication between the internal carotid artery and the cavernous sinus caused by a tear in the artery wall, either traumatic or spontaneous. Other causes include prothrombotic disorders, anemia and trauma. Cerebral venous thrombosis cvt is a rare disease associated with a extremely wide spectrum of clinical presentation, which often delays appropriate diagnosis. Contrastenhanced mri brain shows bulging of the cavernous sinus, increased. The internal carotid artery and the abducens nerve are located medially within the sinus, covered by the endothelial. Septic cst is a rapidly evolving thrombophlebitic process with an infectious origin typically from the middle third of the face, sinuses, ears, teeth, or mouth, affecting the cavernous sinus and its structures. Superior sagittal sinus, transverse, straight and sigmoid sinuses. A keyword search of imaging reports for the terms cerebral venous thrombosis and dural sinus thrombosis was used, and a total of 30 cases of cerebral venous thrombosis were identified, imaged by mr from 1999 to 2005.
Cvt results in an increased venous pressure that can lower cerebral perfusion pressure and induce parenchymal change due to vasogenic edema, cytotoxic edema, or intracranial hemorrhage. Efficacy of t2weighted gradientecho mri in early diagnosis. Venous sinuses located on the median line of the dura mater, connecting the cavernous sinuses of each side explanation of sinus intercavernosi anterior et. A 2yearold boy with known sickle cell disease presented in acute coma. Ecr 2017 c2080 imaging of cerebral venous thrombosis. Symptoms often start within a few days of developing an infection in the face or skull, such as sinusitis or a boil. Tributary venosinus occlusion and septic cavernous sinus thrombosis. The first page of the pdf of this article appears above. Bilateral lower extremity us in the patient with unilateral. Our first case presented with headache, papilledema, 6th nerve palsy, and mri showed transverse sinus thrombosis in combination with obstruction of superior sagittal sinus, and cortical hemorrhage. The abducens nerve cranial nerve vi and the sympathetic plexus around the carotid artery, on the contrary, lie within the cavity of the cavernous sinus in close relation to the ica. Because of variability in clinical presentation and neuroimaging, cvt remains a diagnostic challenge. The imaging appearance of chronic, partially recanalized dural sinus thrombosis has been incompletely described.
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