Everything about Cavernous sinus

Anatomy of cavernous sinus:

From above to downwards, following cranial nerves pass:

• 3
• 4
• V1
• 6
• V2.

Nerve lying closest to the internal carotid artery in cavernous sinus: CN6

Symptoms of cavernous sinus thrombosis:

• Systemic signs of toxemia with high grade fever
• Edema in mastoid region: Pathognomonic sign
• Involvement of V1 & V2: Headache is the MC symptom. The headache is usually sharp, increases progressively, and is usually localized to the regions innervated by the V1 and V2 branches of CN5; accompanied by sensory loss over forehead and chick and impaired corneal reflex.
• Involvement of CN3 & 4: Ophthalmoplegia
• Rapid development of B/L proptosis.
• Involvement of CN6: Loss of abduction (paralysis of LR): 1st sign of B/L cavernous involvement.

Treatment:

• High dose potent broad spectrum IV antibiotics
• Analgesics and anti-inflammatory agents.

Carotid-cavernous fistula:

It is an abnormal communication between the internal carotid artery and the cavernous sinus following an episode of head trauma.

C/F:

• Pulsatile proptosis
• Total external ophthalmoplegia.

O/E: Arterial bruit +ve on auscultation

Rx:

• Small fistula: Balloon tamponade
• Large fistula: Embolization/ Ligation.

More points from anatomy:

Tributaries of cavernous sinus:

Draining channels (see above picture):

• Superior petrosal sinus drains cavernous sinus to transverse sinus
• Inferior petrosal sinus drains cavernous sinus into IJV/ Sigmoid sinus
• The 2 cavernous sinuses are connected by anterior and posterior inter-cavernous sinus
• The 2 cavernous sinuses drain into the pterygoid venous plexus through emissary vein (‘E’ in picture).

Tolosa Hunt syndrome:

• Idiopathic inflammatory condition that involves the cavernous sinus
• There is paresis of one or more of the 3rd, 4th and 6th cranial nerve
• C/F: Painful ophthalmoplegia
• MRI: Thickening of cavernous sinus wall
• Rx: Responds rapidly to oral steroids.

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