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.


  • 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.


  • Pulsatile proptosis
  • Total external ophthalmoplegia.

O/E: Arterial bruit +ve on auscultation


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

More points from anatomy:

Tributaries of cavernous sinus:

From orbit

From meninges

From brain

Superior ophthalmic vein

Inferior ophthalmic vein

Central vein of retina

Spheno-parietal sinus

Superficial middle cerebral vein

Inferior cerebral vein

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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