radiographic features of cavernous sinus...

Liane Dallalzadeh, HMSIII Gillian Lieberman, MD

Core Radiology Clerkship

Radiographic Features of Cavernous Sinus Thrombosis

February 2017

Learning Objectives 1. Recognize the symptomatology of cavernous sinus

thrombosis through a case presentation 2. Review paranasal sinus, orbit, and cerebral venous

system anatomy. 3. Consider the menu of radiologic tests for evaluating

proptosis and painful vision loss. 4. Interpret the radiologic features of our patient’s

imaging and consider their differential diagnoses. 5. Provide a case summary and take home points.

Liane Dallalzadeh, MS3 Gillian Lieberman, MD

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Our Patient: Clinical Presentation • CC: Headache

• HPI: 72 year-old female presented to emergency room with frontal headache

lasting 4 days. • ROS: Limited secondary to somnolence:

• Denies neck stiffness, photophobia, double vision, flashes, or floaters • Endorses nasal congestion, adds that she feels like her eyes are swollen

• PMH:

• Systemic Lupus Erythematosus (on steroids) • Type 2 Diabetes Mellitus (on insulin) • History of L sided stroke without residual deficits

• Exam: Somnolent with PERRL and bilateral proptosis with mild erythema over R

eyelid. Otherwise, exam unremarkable. • Labs: Notable for WBC 12.4K with 86% PMNs • CT Head w/o contrast: Notable for opacification of bilateral maxillary and

sphenoid sinuses, scattered fluid in ethmoid air cells, hyperostosis of sphenoid sinus, suggestive of acute on chronic sinusitis.


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Ophthalmology consulted with positive exam findings of: • Bilateral proptosis OD > OS • EOM:

• OD -2.5 restriction in all directions of gaze • OS -0.5 restriction in all directions of gaze

• Lid/Lashes/Lacrimal • OD: Periorbital edema, erythema, warmth • OS: Upper lid fullness, non-erythematous, non-tender

• Conjunctiva • OD: 360-degree chemosis • OS: Inferior chemosis

ENT consulted with endoscopic exam findings of: • Nasal cavity with mucus, mildly edematous turbinates, crusting near

osteomeatal complex (OMC) bilaterally • No frank purulence for culture

Our Patient: Hospital Day 2 Liane Dallalzadeh, MS3 Gillian Lieberman, MD

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Overnight, progression of our patient’s exam included •Eyes:

• Visual acuity 20/200 OD 20/100 OS • Pupils minimally reactive, ptosis • Pain with OU movement • Prominent periorbital edema with

purulence and crusting around eyes.

•Nose/Sinuses: No tenderness to palpation of frontal or maxillary sinuses. •Neuro: Tenderness to palpation of CNV1 distribution bilaterally.

Our Patient: Hospital Day 3 Liane Dallalzadeh, MS3 Gillian Lieberman, MD

Image: Hamrah, P et al. UptoDate

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Our patient’s cumulative presentation of bilateral periorbital edema, proptosis, and chemosis in the context of acute on

chronic sinusitis is most concerning for orbital cellulitis.

Her rapid progression of reduced visual acuity with bilateral ophthalmoplegia and minimally reactive pupils suggests

cranial nerve dysfunction, specifically of CNs 3, 4, 6.

Let us review orbital, paranasal sinus, and cerebral venous anatomy to gain a better understanding of how her

symptomatology summates.


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Paranasal Sinuses

Images: LoGerfo, SE et al. http://uwmsk.org/sinusanatomy2/Sphenoid-Normal.html

MS = Maxillary Sinus NLD = Nasolacrimal duct IT = inferior turbinate

SpS = Sphenoid Sinus AE, PE = Anterior Ethmoid, Posterior Ethmoid CC = Carotid canal


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http://uwmsk.org/sinusanatomy2/Sphenoid-Normal.html

• Superior orbital septum connects the periosteum of the superior orbital rim to the levator aponeurosis.

• Inferior orbital septum connects the periosteum of the inferior orbital rim with the inferior tarsal plate.

• Together, both comprise the orbital septum which separates the preseptal and orbital spaces.

Orbital Septum

Image: Steinkuller, PG and Jones, DB. < http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v4/v4c025.html>


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Four rectus muscles (MR, LR, IR, SR) and their intermuscular septa divide the orbit into two compartments: intraconal and extraconal spaces.

Orbital Compartments

Image: Steinkuller, PG and Jones, DB. < http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v4/v4c025.html>


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Orbit on CT

Image: Tailor, TD et al. http://pubs.rsna.org/doi/full/10.1148/rg.336135502


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Orbital Venous System

Image: Kumar JB et al. https://www.aao.org/eyenet/article/diagnosis-management-of-superior-ophthalmic-vein-t?may-2015

The superior ophthalmic vein and a branch of inferior ophthalmic vein pass through superior orbital fissure into cavernous sinus.


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Cavernous Sinus

Image: Blumenfeld H. Neuroanatomy through Clinical Cases. 2nd Edition. Sunderland, MA. Sinauer Associates, Inc. 2010. p.133

• The cavernous sinus receives deoxygenated blood from eye and superficial cortex.

• It is bordered by

the temporal bone, sphenoid bone, and sella turcica.


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Cavernous Sinus

Image: Blumenfeld H. Neuroanatomy through Clinical Cases. 2nd Edition. Sunderland, MA. Sinauer Associates, Inc. 2010. p.583

A number of critical neurovascular structures border or transverse the cavernous sinus including

• Internal Carotid Artery • CN III, IV, VI responsible for extraocular movements • CNV1 and V2 responsible for facial somatosensation and corneal reflex (V1) • CN II responsible for visual perception • Sella turcica housing the pituitary


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Cavernous Sinus

Image: Skugor M, Hamrahian AH. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/pituitary-disorders/

Here the cavernous sinus and its surrounding neurovascular structures can be seen on coronal MRI. Notice the convex lateral border of the cavernous sinus (outlined in white).


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Now, let us consider the imaging modalities that would be most beneficial in

determining the underlying cause of our patient’s proptosis and painful vision loss.


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ACR Appropriateness Criteria:

Chart: Orbit, Vision, and Visual Loss.. American College of Radiology Appropriateness Criteria. <https://acsearch.acr.org/docs/69486/Narrative/>


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Menu of Tests: CT 1. Strengths:

• Faster speed • Relatively lower cost with greater availability • Preferred modality if evaluating bony structures • Preferred modality if paranasal sinus disease is likely etiology

2. Weaknesses: • Radiation exposure • Poorer soft-tissue resolution relative to MRI

3. Notes: • Ordering a “head CT” typically does not provide appropriate detail of

the orbits, it is important to specify or select “CT orbits, sella, internal auditory canal” if provided.


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Menu of Tests: MRI 1. Strengths:

• Better evaluation of soft tissue details including optic nerve and the intraconal and extraconal spaces

• Better evaluation of dilated orbital veins and regional venous sinuses • Absence of radiation exposure

2. Weaknesses: • Slower speed • Relatively greater cost with more limited availability

3. Notes:

• MRI is reserved for patients with suspected intracranial involvement, including the cavernous sinus or fungal infection.

• Contraindications include intraocular metallic foreign body and MRI incompatible devices (certain implanted hearing aids, neurostimulators, intracranial metal clips, pacemakers, etc)


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With an understanding of the relative strengths and weaknesses of both CT and MRI for evaluating proptosis and painful vision loss, we are ready to review our

patient’s images.

We will start with her initial non-contrast head CT in the emergency department.


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Our Patient: CT- Head at level of maxillary sinuses

Notice: •Air- fluid level within L maxillary sinus •Soft tissue density fluid-filled R maxillary sinus These findings are suggestive of acute sinusitis


Image: PACS, BIDMC 20

Notice: •Hyperostosis of sphenoid sinus walls suggestive of chronic sinusitis.

Sclerosis is secondary to chronic mucoperiosteal reaction.

Our Patient: CT- Head at level of sphenoid sinuses (bone window)



Our Patient: CT- Head at level of sphenoid sinuses (soft tissue window)

Notice: •Opacification of bilateral sphenoid sinuses.

DDX for this finding includes: • Acute sinusitis • Chronic sinusitis • Fungal sinusitis

Q: What past medical history may predispose our patient to fungal sinusitis? Immunosuppression from her history of T2DM and steroid use for SLE!



Next, we will review a CT with contrast of the orbits, sella, and internal auditory

canal obtained after our patient developed bilateral proptosis and ophthalmoplegia on

hospital day 2.


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Notice: Proptosis and soft tissue prominence of periorbital tissues with extension along bilateral zygoma. Bilateral retrobulbar fat stranding with loss of intraconal fat planes These are concerning for orbital cellulitis. DDX includes: •Preseptal cellulitis •Orbital abscess •Orbital pseudotumor •Thyroid associated orbitopathy •Orbital lymphoma

Our Patient: CT+ Orbits, Sella, and Internal Auditory Canal Liane Dallalzadeh, MS3 Gillian Lieberman, MD


Our Patient: CT+ Orbits, Sella, and Internal Auditory Canal

Notice: Superior ophthalmic vein enlargement with vague enhancement of walls, concerning for thrombophlebitis.



Companion Case: Enhancement of SOV

Another view in a companion case: Enlargement of vein with wall enhancement is due to venous congestion. This may be secondary to a thrombus and resultant inflammation.



Lastly, our patient received a MRI of the head with and without contrast for further

work-up of her CT findings.

Here we will review the MRI of a companion case which superbly

demonstrates important findings in the cavernous sinus.


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Notice: Hyperintense enhancement at the bilateral cavernous sinuses The cavernous sinus border is now concave suggesting expansion.

Companion Case: Coronal T2 MRI Liane Dallalzadeh, MS3 Gillian Lieberman, MD


Companion Case: Axial T2 MRI

Notice: Expansion and inflammatory changes at the bilateral cavernous sinuses DDX includes: •Tolosa Hunt syndrome •Carotid cavernous fistula



• Radiographic findings were cumulatively consistent with bilateral orbital cellulitis

that had progressed to cavernous sinus thrombosis. • Our patient underwent CT-guided endoscopic sinus drainage emergently. Sinus

tissue specimens were negative for fungi, however blood cultures were positive for gram positive cocci.

• Post-operatively, our patient was continued on high-dose IV antibiotics and anticoagulated with a heparin drip before being bridged to warfarin.

• She experienced marked improvement in her vision and extraocular motility, without pain or periorbital edema by time of discharge.

Our Patient: Outcome Liane Dallalzadeh, MS3 Gillian Lieberman, MD

Image: Wulc, AE and Edmonson, BC. http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v2/v2c034.html 30

Cavernous Sinus Thrombosis Liane Dallalzadeh, MS3 Gillian Lieberman, MD

Pathogenesis: Septic thrombus forms within the cavernous sinus as a result of 1) orbital infections that drain via ophthalmic veins 2) sphenoid or ethmoid sinus infections via extension into the orbit or cavernous sinus directly 3) dental infections that drain via pterygoid venous plexus

Clinical Manifestations: • Headache – over CNV1/V2 distributions • Altered Mental Status • Fever • Periorbital edema • Ophthalmoplegia- first CN6 lateral gaze palsy • Ptosis and/or mydriasis • Reduced visual acuity secondary to papilledema

Treatment: • High-dose intravenous antibiotics: Include coverage for community-acquired

MRSA • Surgery: Endoscopic sinus drainage EMERGENTLY • Anticoagulation • Glucocorticoids after antibiotic course to reverse inflammatory damage to CNs

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Learning Objectives

We learned the pathogenesis, clinical manifestations, and treatment of cavernous sinus syndrome. We reviewed the relevant paranasal sinus, orbital, and cerebral

venous anatomy including the critical neurovascular structures that transverse the cavernous sinus. We learned the menu of radiologic tests appropriate for

evaluating proptosis and painful vision loss including CT and MRI. We identified the radiologic features of sinusitis, orbital

cellulitis, and cavernous sinus thrombosis in addition to their differential diagnoses.


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References • Hamrah P, Dana R. “Allergic Conjunctivitis: Management” UptoDate. Available at https://www.uptodate.com/contents/allergic-

conjunctivitis-management?source=search_result&search=allergic%20conjunctivitis&selectedTitle=1~111. Accessed February 2017 • LoGerfo, SE et al. “Interactive CT Sinus Anatomy.” Available at http://uwmsk.org/sinusanatomy2/Sphenoid-Normal.html. Accessed

February 2017. • Steinkuller, PG and Jones, DB. ‘’Chapter 25: Microbial Preseptal and Orbital Cellulitis.” Duane’s Ophthalmology. Available at

http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v4/v4c025.html. Accessed February 2017. • Tailor, TD et al. (2013) Orbital Neoplasms in Adults: Clinical, Radiologic, and Pathologic Review. RSNA Radiographics, 3 (6): 1739-

58. DOI: http://dx.doi.org/10.1148/rg.336135502 • Kumar JB et al. (2015) “Diagnosis and Management of Superior Ophthalmic Vein Thrombosis.” Ophthalmic Pearls, EyeNet Magazine,

American Academy of Ophthalmology. Available at https://www.aao.org/eyenet/article/diagnosis-management-of-superior-ophthalmic-vein-t?may-2015. Accessed February 2017.

• Blumenfeld H. (2010) Neuroanatomy through Clinical Cases. 2nd Edition. Sunderland, MA. Sinauer Associates, Inc. • Skugor M, Hamrahian AH. (2012) “Pituitary Disorders.” Cleveland Clinic: Center for Continuing Education. Available at

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/pituitary-disorders/. Accessed February 2017. • American College of Radiology. Orbit, Vision, and Visual Loss: Appropriateness Criteria. Available at

https://acsearch.acr.org/docs/69486/Narrative/. Accessed February 2017. • American Academy of Ophthalmology. “Orbital Cellulitis.” Available at

https://www.aao.org/focalpointssnippetdetail.aspx?id=1b0ef397-e539-4c0d-8608-55bb5c621c94. Accessed February 2017. • Broderick, DF. (2015) “The opacified paranasal sinus: Approach and differential.” Applied Radiology: 9-17. • LeBedis CA, Sakai, O. (2008) “Nontraumatic Orbital Conditions: Diagnosis with CT and MR Imaging in the Emergent Setting.” RSNA

Radiographics, 28(6): 1741-1753. DOI:http://dx.doi.org/10.1148/rg.286085515 • Abdel Razek AAK, Castillo M (2009) “Imaging Lesions of the Cavernous Sinus.” American Journal of Neuroradiology, 30: 444-452.

DOI: 10.3174/ajnr.A1398 • Southwick FS. “Septic dural sinus thrombosis.” UptoDate. Available at https://www.uptodate.com/contents/septic-dural-sinus-

thrombosis?source=machineLearning&search=cavernous%20sinus%20thrombosis&selectedTitle=2~27&sectionRank=1&anchor=H2#H2. Accessed February 2017.


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https://www.uptodate.com/contents/allergic-conjunctivitis-management?source=search_result&search=allergic%20conjunctivitis&selectedTitle=1%7E111

https://www.uptodate.com/contents/allergic-conjunctivitis-management?source=search_result&search=allergic%20conjunctivitis&selectedTitle=1%7E111

http://uwmsk.org/sinusanatomy2/Sphenoid-Normal.html

http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v4/v4c025.html

https://www.aao.org/eyenet/article/diagnosis-management-of-superior-ophthalmic-vein-t?may-2015

https://www.aao.org/eyenet/article/diagnosis-management-of-superior-ophthalmic-vein-t?may-2015

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/pituitary-disorders/

https://acsearch.acr.org/docs/69486/Narrative/

https://www.aao.org/focalpointssnippetdetail.aspx?id=1b0ef397-e539-4c0d-8608-55bb5c621c94

https://www.uptodate.com/contents/septic-dural-sinus-thrombosis?source=machineLearning&search=cavernous%20sinus%20thrombosis&selectedTitle=2%7E27&sectionRank=1&anchor=H2#H2



• Dr. Rafeeque Bhadelia, MD • Dr. Yu-Ming Chang, MD, PhD • Dr. Alexei Kudla, MD • Laurel Baxter, Clerkship Coordinator


Acknowledgments

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