Zakrzepica zatoki jamistej – Diagnostyka i diagnoza

Zakrzepica zatoki jamistej
Diagnostyka i diagnoza

Zakrzepica zatoki jamistej (CST) to rzadkie, ale potencjalnie śmiertelne powikłanie infekcji twarzoczaszki, zatok, oczodołu czy gardła, które wymaga szybkiego rozpoznania i leczenia. Klinicznie charakteryzuje się wysoką gorączką, silnym bólem głowy w okolicy oczodołowej, obrzękiem okołooczodołowym, porażeniem nerwów okoruchowych oraz zaburzeniami widzenia i świadomości. Diagnostyka opiera się na badaniach obrazowych, gdzie tomografia komputerowa z kontrastem i wenografią (CTV) wykazuje czułość około 95%, natomiast MRI z wenografią (MRV) jest preferowaną metodą ze względu na wyższą czułość i możliwość oceny wieku zakrzepu. W badaniach laboratoryjnych obserwuje się leukocytozę, podwyższone OB, CRP i D-dimery, jednak prawidłowy poziom D-dimerów nie wyklucza CST. Badania w kierunku trombofilii powinny być wykonywane po zakończeniu terapii przeciwzakrzepowej. Nakłucie lędźwiowe nie jest rutynowo zalecane, chyba że istnieje podejrzenie zapalenia opon mózgowo-rdzeniowych.

Diagnostyka zakrzepicy zatoki jamistej

Zakrzepica zatoki jamistej (CST – Cavernous Sinus Thrombosis) to rzadkie, zagrażające życiu schorzenie, które może rozwinąć się jako powikłanie infekcji twarzoczaszki, zapalenia zatok, zapalenia tkanki łącznej oczodołu, zapalenia gardła lub ucha, a także po urazie lub zabiegu chirurgicznym, zwłaszcza u pacjentów z zaburzeniami zakrzepowymi. ¹² Jej wczesne rozpoznanie jest kluczowe dla dobrego rokowania, ponieważ przed erą antybiotyków zakrzepica zatoki jamistej prawie zawsze kończyła się śmiercią, a obecnie ponad 70% pacjentów przeżywa przy odpowiednim leczeniu. ³

Objawy kliniczne sugerujące zakrzepicę zatoki jamistej

Diagnoza CST jest często opóźniona ze względu na rzadkość występowania tej choroby oraz jej niespecyficzną prezentację kliniczną. Może ona naśladować inne stany, takie jak zapalenie tkanki łącznej oczodołu, migrena czy zapalenie opon mózgowo-rdzeniowych. ⁴⁵ Rozpoznanie CST należy rozważyć u pacjentów z następującymi objawami:

Gorączka – często wysoka i o zmiennym charakterze ¹⁶
Ból głowy – zwykle silny, zlokalizowany w okolicy oczodołowej ⁷
Objawy oczne – obrzęk okołooczodołowy, chemoza (obrzęk spojówki), wytrzeszcz oczu, porażenie nerwów okoruchowych ⁷⁶
Zaburzenia widzenia – podwójne widzenie, zaburzenia ostrości wzroku ⁷
Objawy neurologiczne – porażenie mięśni oka, opadanie powieki, rozszerzenie źrenicy, zaburzenia czucia w zakresie nerwu ocznego i szczękowego ⁷⁸
Zaburzenia świadomości – splątanie, senność, śpiączka ⁷

Charakterystyczną cechą CST jest początkowe wystąpienie objawów jednostronnie, a następnie rozprzestrzenianie się na drugą stronę, co związane jest z anatomią zatoki jamistej i jej połączeniami. ⁹

Badania obrazowe w diagnostyce zakrzepicy zatoki jamistej

Złotym standardem w diagnostyce zakrzepicy zatoki jamistej są badania neuroobrazowe. Ze względu na potencjalnie zagrażający życiu charakter CST i możliwość szybkiego postępu choroby, leczenie często rozpoczyna się przed potwierdzeniem rozpoznania na podstawie podejrzenia klinicznego. ⁴

Tomografia komputerowa (CT)

Tomografia komputerowa jest często pierwszym badaniem wykonywanym u pacjentów z podejrzeniem CST ze względu na jej dostępność, jednak ma ona pewne ograniczenia: ¹⁰¹¹

CT bez kontrastu może wykazać zwiększoną gęstość w zakresie zatoki jamistej, ale zmiany mogą być subtelne ¹⁰
CT z kontrastem może ujawnić ubytki wypełnienia w zatoce jamistej oraz pogrubienie górnej żyły ocznej ¹⁰
Ujemny wynik CT nie wyklucza CST przy wysokim podejrzeniu klinicznym ¹⁰¹²
CT może wykazać pośrednie objawy, takie jak wytrzeszcz oczu i poszerzenie górnej żyły ocznej ¹³

W przypadku CT z wenografią (CTV) czułość wzrasta do około 95%, co czyni ją wiarygodnym badaniem, zwłaszcza gdy MRI nie jest dostępne. ¹¹¹⁴

Rezonans magnetyczny (MRI)

MRI z wenografią (MRV) jest preferowaną metodą obrazowania w diagnostyce CST: ¹⁵¹⁶

MRI wykazuje większą czułość niż CT, szczególnie w wykrywaniu zakrzepicy żył korowych ⁹
W obrazach T1 i T2 widoczny jest brak typowego sygnału przepływu w zatoce jamistej ¹⁶
Charakterystyka sygnału zakrzepu zmienia się w zależności od jego wieku ¹⁷
MRV pozwala uwidocznić brak przepływu żylnego w zajętej zatoce jamistej ¹⁰

W literaturze sugeruje się wykonanie zarówno CT jak i MRI, zwłaszcza MRI z obrazowaniem dyfuzyjnym – CT jako pierwsze badanie (ze względu na większą dostępność i szybkość), a następnie MRI, szczególnie jeśli wynik CT nie jest jednoznaczny. ¹⁰

Badania laboratoryjne

Badania laboratoryjne nie są specyficzne dla CST, ale mogą pomóc w potwierdzeniu obecności infekcji oraz w ocenie czynników sprzyjających zakrzepicy: ¹⁸

Morfologia krwi – zwykle wykazuje leukocytozę z przesunięciem w lewo ¹⁸¹⁹
Posiewy krwi – często dodatnie, identyfikujące czynnik wywołujący infekcję ¹⁸²⁰
Markery stanu zapalnego – zwiększone wartości OB, CRP, D-dimerów ¹⁹²¹
Badania w kierunku trombofilii – przeciwciała antyfosfolipidowe i antykardiolipinowe, białko S i C, antytrombina III, czynnik V Leiden ²⁰⁸

Warto zaznaczyć, że badania w kierunku trombofilii mogą dawać fałszywe wyniki podczas leczenia przeciwzakrzepowego i powinny być opóźnione do zakończenia terapii. ¹¹⁹ Ponadto, mimo że D-dimery mogą być podwyższone w ostrej CST, prawidłowy poziom D-dimerów nie wyklucza rozpoznania. ²²²³

Nakłucie lędźwiowe

Nakłucie lędźwiowe (punkcja lędźwiowa) może być pomocne w różnicowaniu CST od bardziej zlokalizowanych procesów, takich jak zapalenie zatok czy zapalenie tkanki łącznej oczodołu, oraz w wykluczeniu zapalenia opon mózgowo-rdzeniowych, które może być powikłaniem CST: ¹⁰³

Płyn mózgowo-rdzeniowy wykazuje obecność komórek zapalnych w około 75% przypadków ¹⁰
Badanie płynu mózgowo-rdzeniowego może wykazać objawy przyoponowego stanu zapalnego lub jawnego zapalenia opon mózgowo-rdzeniowych ¹⁸

Niektórzy autorzy zalecają wykonanie nakłucia lędźwiowego tylko u pacjentów z podejrzeniem zapalenia opon mózgowo-rdzeniowych lub encefalopatii, a zgodnie z nowszymi wytycznymi europejskimi nakłucie lędźwiowe nie jest wskazane jako rutynowe postępowanie diagnostyczne w przypadku CST. ²⁴²³

Różnicowanie diagnostyczne zakrzepicy zatoki jamistej

Zakrzepicę zatoki jamistej należy różnicować z innymi stanami, które mogą prezentować podobne objawy kliniczne: ⁷²⁵

Zapalenie tkanki łącznej oczodołu – zwykle jednostronne, bez objawów porażenia nerwów czaszkowych ²
Zapalenie opon mózgowo-rdzeniowych – podobne wczesne objawy kliniczne, takie jak gorączka, ból głowy, wymioty i sztywność karku ⁷
Ostre jaskra zamykającego się kąta – silny ból oka, zaczerwienienie, nudności i wymioty ²⁵
Guzy wewnątrzczaszkowe – objawy wzrostu ciśnienia wewnątrzczaszkowego, zaburzenia neurologiczne ²⁵
Przetoka szyjno-jamista – wytrzeszcz oczu, szum w uchu, poszerzenie naczyń spojówkowych ²⁵
Zespół Tolosa-Hunta – ból oczodołowy, porażenie mięśni zewnętrznych oka ²⁵

Różnicowanie tych stanów jest istotne, ponieważ zakrzepica zatoki jamistej wymaga pilnego leczenia antybiotykami i potencjalnie lekami przeciwzakrzepowymi, podczas gdy inne schorzenia mogą wymagać odmiennego podejścia terapeutycznego. ¹²²⁶

Podejście diagnostyczne do pacjenta z podejrzeniem zakrzepicy zatoki jamistej

Ze względu na potencjalnie śmiertelne powikłania CST, ważne jest szybkie i systematyczne podejście diagnostyczne: ¹²²⁶

Ocena kliniczna – zebranie wywiadu chorobowego, ze szczególnym uwzględnieniem niedawnych infekcji twarzoczaszki, zatok przynosowych, uzębienia oraz ocena objawów klinicznych ⁵
Badania obrazowe – niezwłoczne wykonanie CT lub MRI z kontrastem; przy wysokim podejrzeniu klinicznym zaleca się wykonanie CT wenografii lub MR wenografii ²¹⁵
Badania laboratoryjne – morfologia krwi, markery zapalne, posiewy krwi i innych płynów ustrojowych ²⁷
Rozważenie nakłucia lędźwiowego – w przypadku podejrzenia zapalenia opon mózgowo-rdzeniowych ³

W przypadku silnego podejrzenia klinicznego CST, leczenie antybiotykami powinno być rozpoczęte niezwłocznie, nawet przed potwierdzeniem rozpoznania badaniami obrazowymi. ²⁸²⁶ Przy rozpoczynaniu leczenia należy skonsultować się z okulistą, specjalistą chorób zakaźnych, a w razie potrzeby z neurochirurgiem. ¹²²⁴

Specyficzne sytuacje diagnostyczne

W pewnych sytuacjach diagnostyka CST może wymagać indywidualnego podejścia:

CST w przebiegu nowotworów – rzadkie przypadki, wymagające starannej oceny ryzyka i korzyści przy rozważaniu leczenia przeciwzakrzepowego ²⁹
CST jako powikłanie mukormykozy – częściej występujące u pacjentów z cukrzycą, nowotworami lub immunosupresją; wymaga wczesnego rozpoznania i leczenia przeciwgrzybiczego ³⁰
CST po szczepieniu przeciwko SARS-CoV-2 szczepionkami wektorowymi – rzadkie powikłanie, które może być związane z ciężką trombocytopenią; wymaga odmiennego podejścia terapeutycznego (przeciwwskazane jest stosowanie heparyny) ³¹³²

W każdym przypadku podejrzenia CST kluczowa jest szybka i dokładna diagnostyka, ponieważ wczesne rozpoznanie i leczenie znacząco poprawiają rokowanie pacjentów. ²¹³³

Wyzwania diagnostyczne i pułapki w rozpoznawaniu zakrzepicy zatoki jamistej

Rozpoznanie zakrzepicy zatoki jamistej może być trudne z kilku powodów: ³⁴¹⁵

Rzadkość występowania schorzenia – ze szacowaną roczną częstością około 0,2-1,6 przypadków na 100 000 osób ³⁵
Niespecyficzna prezentacja kliniczna – objawy mogą naśladować wiele innych schorzeń neurologicznych ³⁶
Zmienny obraz radiologiczny – wczesne zmiany w badaniach obrazowych mogą być subtelne ³⁰
Artefakty przepływu w MRI – mogą prowadzić do fałszywych rozpoznań ³⁴

Lekarze powinni zachować wysoki stopień podejrzenia CST, szczególnie u pacjentów z objawami ocznymi lub zgłaszającymi objawy zgodne z infekcją głowy/szyi w ciągu ostatniego miesiąca. ²⁴ Interesujące jest to, że CT głowy bez kontrastu często nie wykazuje nieprawidłowości, co może prowadzić do opóźnienia w rozpoznaniu. ²⁴

Wczesne i precyzyjne rozpoznanie zakrzepicy zatoki jamistej jest kluczowe dla skutecznego leczenia i dobrego rokowania pacjentów. Podejście diagnostyczne powinno obejmować dokładną ocenę kliniczną, odpowiednie badania obrazowe i laboratoryjne oraz szybkie wdrożenie leczenia przy uzasadnionym podejrzeniu klinicznym, nawet przed ostatecznym potwierdzeniem rozpoznania. ³⁷

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Materiały źródłowe

#1 Cavernous Sinus Thrombosis – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448177/
Cavernous sinus thrombosis (CST) is a rare, life-threatening 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. Early recognition of cavernous sinus thrombosis which, often presents with fever, headache, eye findings such as periorbital swelling, and ophthalmoplegia, is critical for a good outcome. […] This activity examines when cavernous sinus thrombosis should be considered, how to properly evaluate this condition and the role of the interprofessional team in caring for patients with this condition. […] The optimal diagnostic test is neuroimaging with either contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). CT venogram (CTV) and contrast-enhanced MR venogram (MRV) are highly sensitive, whereas non-contrast CT and time-of-flight MRV may miss the diagnosis. […] Screening for thrombophilia may give false results during anticoagulation therapy and should be delayed until after treatment is completed.
#2 Cavernous Sinus Thrombosis – Eye Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/eye-disorders/orbital-diseases/cavernous-sinus-thrombosis
Cavernous sinus thrombosis is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by nasal furuncles or bacterial sinusitis. […] Diagnosis is confirmed by CT or MRI. […] Cavernous sinus thrombosis is often misdiagnosed because it is rare. It should be considered in patients who have signs consistent with orbital cellulitis. […] Diagnosis is based on neuroimaging. MRI is the better study, but CT is also helpful. Contrast-enhanced MR venogram (MRV) and CT venogram are more sensitive than either CT or MRI. […] Obtain immediate neuroimaging with MRI or CT (or contrast-enhanced MR venogram or CT venogram if immediately available).
#3 Cavernous Sinus Thrombosis: Symptoms, Causes & Treatment
https://my.clevelandclinic.org/health/diseases/23520-cavernous-sinus-thrombosis
Cavernous sinus thrombosis requires immediate treatment. Youll likely be admitted into an intensive care unit (ICU) so your provider can monitor you closely. Treatments include: Antibiotics. Your provider will begin antibiotic treatment through an IV to clear the infection thats causing the clot. […] Your provider may check your blood or other body fluids (for example, sinus fluid) for signs of bacteria or other pathogens that are causing your infection. […] A lumbar puncture can show if the infection has spread to your brain, as with meningitis. Meningitis is a complication of cavernous sinus thrombosis. […] Before antibiotics, cavernous sinus thrombosis nearly always resulted in death. Now, more than 70% of people with cavernous sinus thrombosis survive. […] Speak with your provider about the likelihood your condition will lead to complications.
#4 Cavernous Sinus Thrombosis: Symptoms, Causes & Treatment
https://my.clevelandclinic.org/health/diseases/23520-cavernous-sinus-thrombosis
Cavernous sinus thrombosis is a rare blood clot that can form in response to an infection in your face or head. This condition requires immediate treatment. […] Diagnosis can be tricky, as cavernous sinus thrombosis shares symptoms with more common conditions, like an eye infection or a migraine. Still, your healthcare provider may suspect cavernous sinus thrombosis based on your symptoms, especially if you currently have or recently had a sinus infection. […] Your diagnosis may include any of the following tests or procedures: MRI and CT scans allow your provider to identify clots in your cavernous sinuses. An MRI with venogram (MRV) is the most sensitive imaging procedure for this diagnosis. […] Because cavernous sinus thrombosis is a potentially life-threatening condition that can progress quickly, your provider may begin treatment before confirming your diagnosis.
#5 Cavernous sinus thrombosis: Treatment, causes, and more
https://www.medicalnewstoday.com/articles/cavernous-sinus-thrombosis
CST is very rare, so doctors sometimes misdiagnose it. […] A healthcare professional will start by taking a detailed medical history. […] They will then conduct a thorough physical examination focusing on signs such as severe headache, eye pain, eyelid swelling, impaired vision, and neurological deficits. […] MRI or CT scans can provide images of the skull, brain, and cavernous sinuses. […] Blood tests can help determine if there is an elevated white blood cell count, which indicates an ongoing infection. […] Prompt diagnosis is crucial through clinical examination, imaging studies, and blood tests.
#6 Cavernous Sinus Thrombosis — Pediatric EM Morsels
https://pedemmorsels.com/cavernous-sinus-thrombosis-in-children/
Cavernous Sinus Thrombosis is rare, but life-threatening. […] Prompt recognition is key to limiting complications! […] Classic Presentation = severe illness with high, fluctuating fevers in the setting of recent mid-face infection. […] Common symptoms: Severe Headache, Periorbital Swelling, Ptosis, Inability to Move Eyes, Pain / Numbness around midface and eyes, Vision Changes / Double Vision / Loss of Vision, Seizures, High Fevers. […] There is no current consensus guidelines for management of Cavernous Sinus Thrombosis. […] Imaging: Contrast-enhanced CT is useful, but has radiation concerns. […] Contrast-enhanced MRI is more difficult to come by in the ED. […] Therapy typically includes: Antimicrobials, Empiric antibiotics (ex, Cephalosporin AND Metronidazole AND Vancomycin) should be initiated early. […] Anticoagulation: NO consensus on utility of anticoagulation. […] Surgery: Functional Endoscopic Sinus Surgery has been advocated for, but not often required emergently.
#7 Cavernous sinus thrombosis – Symptoms, diagnosis and treatment | BMJ Best Practice US
https://bestpractice.bmj.com/topics/en-us/956
Cavernous sinus thrombosis (CST) is a thrombus formation within the cavernous sinus, which may be either septic or aseptic in origin. […] Diagnosis is usually made through clinical evaluation together with imaging (computed tomography or magnetic resonance imaging). […] Must be differentiated from meningitis. Common early clinical features of both conditions include fever, headache, vomiting, and nuchal rigidity. […] Key diagnostic factors include rapid onset of signs and symptoms (acute septic CST), headache, fever, periorbital edema, chemosis and proptosis, lateral gaze palsy, ophthalmoplegia, and profound sepsis (acute septic CST). […] Other diagnostic factors include ptosis and mydriasis, papilledema and/or retinal-vein dilatation, decreased corneal reflex, hypo- or hyperesthesia in the distribution of the ophthalmic and maxillary nerves, mental state changes (e.g., confusion, drowsiness, coma), clinically detectable primary infection site, meningismus (nuchal rigidity, photophobia, and headache), positive Kernig or Brudzinski signs, seizures, and loss of visual acuity.
#8 Cavernous sinus thrombosis – Symptoms, diagnosis and treatment | BMJ Best Practice
https://bestpractice.bmj.com/topics/en-us/956?locale=es_ES
Cavernous sinus thrombosis (CST) is a thrombus formation within the cavernous sinus, which may be either septic or aseptic in origin. […] Diagnosis is usually made through clinical evaluation together with imaging (computed tomography or magnetic resonance imaging). […] Must be differentiated from meningitis. […] Key diagnostic factors include presence of risk factors, rapid onset of signs and symptoms (acute septic CST), headache, fever, peri-orbital oedema, chemosis and proptosis, lateral gaze palsy, ophthalmoplegia, and profound sepsis (acute septic CST). […] Other diagnostic factors include ptosis and mydriasis, papilloedema and/or retinal-vein dilatation, decreased corneal reflex, hypo- or hyper-aesthesia in the distribution of the ophthalmic and maxillary nerves, mental state changes (e.g., confusion, drowsiness, coma), clinically detectable primary infection site, meningismus (nuchal rigidity, photophobia, and headache), positive Kernig’s or Brudzinski’s signs, seizures, and loss of visual acuity.
#8 Cavernous sinus thrombosis – Symptoms, diagnosis and treatment | BMJ Best Practice
https://bestpractice.bmj.com/topics/en-us/956?locale=es_ES
1st investigations to order include FBC, contrast-enhanced high-resolution CT of head, contrast-enhanced MRI of head, blood culture, microscopy and culture of suppurative fluid or tissue from primary infective source, antiphospholid and anticardiolipin antibodies, protein S and protein C, antithrombin III, factor V Leiden, and haemoglobin electrophoresis. […] Investigations to consider include lumbar puncture with cerebrospinal fluid analysis.
#9 Cavernous sinus thrombosis – Wikipedia
https://en.wikipedia.org/wiki/Cavernous_sinus_thrombosis
Cavernous sinus thrombosis (CST) is the formation of a blood clot within the cavernous sinus, a cavity at the base of the brain which drains deoxygenated blood from the brain back to the heart. […] The diagnosis of cavernous sinus thrombosis is made clinically, with imaging studies to confirm the clinical impression. Proptosis, ptosis, chemosis, and cranial nerve palsy beginning in one eye and progressing to the other eye establish the diagnosis. Cavernous sinus thrombosis is a clinical diagnosis with laboratory tests and imaging studies confirming the clinical impression. […] CBC, ESR, blood cultures and sinus cultures help establish and identify an infectious primary source. Lumbar puncture is necessary to rule out meningitis. […] Sinus films are helpful in the diagnosis of sphenoid sinusitis. Opacification, sclerosis, and air-fluid levels are typical findings. Contrast-enhanced CT scan may reveal underlying sinusitis, thickening of the superior ophthalmic vein, and irregular filling defects within the cavernous sinus; however, findings may be normal early in the disease course. An MRI using flow parameters and an MR venogram are more sensitive than a CT scan and are the imaging studies of choice to diagnose cavernous sinus thrombosis. Findings may include deformity of the internal carotid artery within the cavernous sinus, and an obvious signal hyperintensity within thrombosed vascular sinuses on all pulse sequences.
#10 Cavernous Sinus Thrombosis Workup: Laboratory Studies, Imaging Studies, Procedures
https://emedicine.medscape.com/article/791704-workup
The literature suggest using both CT and MRI, particularly diffusion weighted MRI; CT first (since it is generally faster and more available) and then MRI, especially if the CT is not definitive. […] MRI with MR venogram (MRV) is the preferred imaging choice as the MRV will show the absence of venous flow in the affected cavernous sinus. […] On noncontrast CT, thrombosis of the cavernous sinus can be appreciated as increased density. The introduction of intravenous contrast can reveal filling defects within the cavernous sinus as well as thickening of the superior ophthalmic vein. Nevertheless, CT scan findings may be subtle, and a negative CT scan cannot rule out CST reliably when the clinical suspicion is high. […] Lumbar puncture may be helpful in distinguishing CST from more localized processes (e.g., sinusitis, orbital cellulitis). Lumbar puncture reveals inflammatory cells in approximately 75% of cases.
#11 Cavernous sinus thrombosis – WikEM
https://wikem.org/wiki/Cavernous_sinus_thrombosis
MRI with MR Venogram – study of choice […] CT head Venogram acceptable choice if no MR available with 95% sensitivity […] CT findings can be subtle and if clinical suspicion is high cannot rule out with a negative CT.
#12 Cavernous Sinus Thrombosis – Diagnosis and Treatment – County EM
http://blog.clinicalmonster.com/2017/12/21/congested-picked-nose-developed-cavernous-sinus-thrombosis/
CT of the head and orbits with IV contrast will show a filling defect in the cavernous sinus along with bulging of the lateral margins of the cavernous sinus. […] CT findings may be subtle, and a negative CT cannot rule out CST when the clinical suspicion is high. […] An initial approach should include broad spectrum antibiotics such as vancomycin, ceftriaxone, and metronidazole. […] There is no clear benefit to clot retrieval. […] The purported benefit is to prevent propagation of the thrombus, but this must be weighed against the risk of hemorrhage, especially if the patient is a candidate for surgery. […] One should consult ophthalmology and infectious disease emergently. If necessary, surgery can be called to assist with source control. Patients with septic CST should be admitted to the hospital with consideration of a critical care setting given the high morbidity and mortality.
#13 Imaging Lesions of the Cavernous Sinus | American Journal of Neuroradiology
https://www.ajnr.org/content/30/3/444
Enhancement of the peripheral margins of an enlarged CS may suggest a clot within it. […] Indirect signs that help to suggest the diagnosis are dilation of the superior ophthalmic veins, exophthalmos, and increased dural enhancement along the lateral border of CS and ipsilateral tentorium. […] The presence of sinusitis and appropriate clinical symptoms confirm the diagnosis.
#14 Cerebral Venous Thrombosis: Pearls and Pitfalls – emDocs
https://www.emdocs.net/cerebral-venous-thrombosis-pearls-and-pitfalls/
Due to the wide variety of symptoms, delays in diagnosis are common. CVT must be considered in patients under 50 years of age with headaches and atypical features. Atypical features may include focal, objective neurologic deficit(s) (often not fitting a specific anatomical region or with multiple region involvement), seizures, signs of intracranial hypertension, or hemorrhagic infarction present on initial head CT. […] Imaging is required for diagnosis. The American Heart Association/American Stroke Associations (AHA/ASA) recommend imaging of the cerebral venous system for patients with infarction across multiple arterial territories or with lobar intracerebral hemorrhage of unclear origin. […] Head computed tomography (CT) is a first line test in patients with new headache, focal neurologic symptom, seizure, or altered mental status.
#15 Cavernous Sinus Thrombosis: Efficiently Recognizing and Treating a Life-Threatening Condition
https://pmc.ncbi.nlm.nih.gov/articles/PMC8451531/
Cavernous sinus thrombosis (CST) can develop as a result of both infectious and noninfectious conditions. […] Although CT can be useful, MRI is likely to be the preferred diagnostic method. […] The gold standard test modality is an MRI with a magnetic resonance venogram (MRV). […] Despite modern advancements, diagnosing CST is a difficult undertaking. […] CT and MRI imaging are the most optimal diagnostic tests and can sometimes show early signs of clot formation which can greatly benefit management and case outcome. […] Patients with risk factors and ocular symptoms suggestive of CST should undergo early diagnostic imaging with contrast-enhanced CT or MRI.
#16 Cavernous sinus thrombosis diagnostic study of choice – wikidoc
https://www.wikidoc.org/index.php/Cavernous_sinus_thrombosis_diagnostic_study_of_choice
Magnetic resonance imaging (MRI) with MR venography is the gold standard test for the diagnosis of cavernous sinus thrombosis. The following findings on performing MRI are confirmatory for cavernous sinus thrombosis: Absent flow void in T1 and T2 and signal characteristics vary depending on the age of the thrombus but will be abnormal. Contrast-enhancement or lack of is not a reliable indicator as organising thrombus can enhance. Diagnosis can generally be made on venography. […] Magnetic resonance imaging (MRI) with MR venography is the gold standard test for the diagnosis of cavernous sinus thrombosis. […] The following findings on performing MRI are confirmatory for cavernous sinus thrombosis: Absent flow void, signal characteristics vary depending on the age of the thrombus but will be abnormal. […] Diagnosis can generally be made on venography.
#17 Cerebral Venous and Dural Sinus Thrombosis – EyeWiki
https://eyewiki.org/Cerebral_Venous_and_Dural_Sinus_Thrombosis
Cerebral venous sinus thrombosis (CVST) is a clot in the venous drainage system of the brain and can present to ophthalmology. […] The clinical presentation of a CVST can be variable and the diagnosis should be suspected in patients with new onset focal neurological deficits, signs of increased ICP, seizures, or mental status changes. A complete ocular exam including dilated fundus examination, visual field examination, and optic nerve photographs are recommended in patients with CVST. […] MRI T2 weighted imaging with MRV is the most sensitive test for identifying CVST. The appearance on MRI is dependent on the age of the thrombus. In the acute setting (days 1-5), the thrombus is typically hypointense on T2 and isointense on T1 weighted MRI. The subacute thrombosis (days 6-15) is usually strongly hyperintense on both T1 and T2 weighted images. After 3 weeks, the signal becomes irregular and either flow was restored or a persistent thrombus was seen.
#18 Cavernous Sinus Thrombosis Workup: Laboratory Studies, Imaging Studies, Procedures
https://emedicine.medscape.com/article/791704-workup
Cavernous sinus thrombosis (CST) is a clinical diagnosis and lab studies are seldom specific. Most patients exhibit a polymorphonuclear leukocytosis, often marked with a shift toward immature forms. Examination of the cerebrospinal fluid is consistent with either a parameningeal inflammation or frank meningitis. Blood culture results generally are positive for the offending organism. […] One study by Misra et al showed that a D-dimer may be useful in patients with suspected cortical sinus venous thrombosis (CSVT). […] In current practice, computed tomography (CT) scan or magnetic resonance imaging (MRI) with contrast is the modality of choice to confirm the diagnosis of CST and to differentiate it from alternatives such as orbital cellulitis, which may have a similar clinical presentation.
#19
https://europepmc.org/books/n/statpearls/article-19035/?extid=32965912&src=med
Blood studies may reveal elevations in the white blood cell count (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR,) and D-dimer. Blood cultures should be obtained routinely and are frequently positive. […] Screening for thrombophilia may give false results during anticoagulation therapy and should be delayed until after treatment is completed.
#20 Cavernous sinus thrombosis – Symptoms, diagnosis and treatment | BMJ Best Practice US
https://bestpractice.bmj.com/topics/en-us/956
1st tests to order include CBC, contrast-enhanced high-resolution CT of head, contrast-enhanced MRI of head, blood culture, microscopy and culture of suppurative fluid or tissue from primary infective source, antiphospholid and anticardiolipin antibodies, protein S and protein C, antithrombin III, factor V Leiden, and hemoglobin electrophoresis. […] Tests to consider include lumbar puncture with cerebrospinal fluid analysis.
#21 Cavernous Sinus Thrombosis â Need for Early Recognition: A Case Report | RGUHS Journal of Dental Sciences | Journalgrid
https://journalgrid.com/view/article/rjds/1198
An uncommon, yet severe condition, Cavernous sinus thrombosis (CST) arises from sinus infections, most commonly in the ethmoid or the sphenoid, and less commonly from odontogenic or otogenic. […] This article highlights the severity of CST, along with the need for its early recognition, diagnosis, and different treatment modalities. […] Prompt recognition of the disorder is essential in reducing complications. […] The highly sensitive tests to diagnose CST are neuroimaging either with contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI), CT venogram, and contrast-enhanced MR venogram. […] Blood studies often reveal an elevated WBC count, D-dimer, ESR, and CRP. […] Meningitis has to be ruled out by performing lumbar punctures. […] The first line of treatment for CST includes antimicrobial therapy, specifically an anti-staphylococcal agent such as vancomycin. […] The favorable outcome depends on early diagnosis and treatment with high-dose IV antibiotics.
#22 Cerebral venous thrombosis – Knowledge @ AMBOSS
https://www.amboss.com/us/knowledge/cerebral-venous-thrombosis/
Diagnosis of CVT is based on neuroimaging with venography. Laboratory studies can help identify underlying conditions (e.g., infections) and to assess baseline organ function prior to therapy. […] Preferred modalities include MRI head with MR venography (MRV): modality of choice (highest sensitivity) and CT head with CT venography (CTV): if MRI is unavailable or is contraindicated. […] Additional evaluation includes routine laboratory studies such as D-dimer, which is typically elevated in acute disease, and normal levels indicate a lower probability for CVT but do not exclude the diagnosis.
#23 Cerebral venous thrombosis – epidemiology, diagnosis and treatment | Tidsskrift for Den norske legeforening
https://tidsskriftet.no/en/2018/08/klinisk-oversikt/cerebral-venous-thrombosis-epidemiology-diagnosis-and-treatment
Cerebral venous thrombosis is a rare condition, but nevertheless among the most common causes of stroke in persons under 45 years of age. The diagnosis and management of cerebral venous thrombosis have been well described in the international scientific literature. […] New-onset non-episodic headache associated with neurological deficits should always be investigated. Cerebral venous thrombosis should be suspected in cases of new-onset progressive headache, and especially where there are known predisposing factors such as thrombophilia, pregnancy, childbirth or the use of hormonal contraceptives. No specific laboratory tests confirm the diagnosis. An elevated D-dimer level may support the diagnosis, but a normal D-dimer level is not sufficient to rule out the condition. […] Upon strong clinical suspicion of cerebral venous thrombosis, or if head CT reveals lobar intraparenchymal haemorrhage or infarct-related lesions that do not follow the usual arterial tree, further diagnostic imaging must be performed.
#23 Cerebral venous thrombosis – epidemiology, diagnosis and treatment | Tidsskrift for Den norske legeforening
https://tidsskriftet.no/en/2018/08/klinisk-oversikt/cerebral-venous-thrombosis-epidemiology-diagnosis-and-treatment
Both CT- and MR venography can confirm a diagnosis of cerebral venous thrombosis, but MR venography is probably more sensitive in the acute phase. […] Testing of all patients for thrombophilia has been recommended previously, but this no longer features in European guidelines owing to weak supporting evidence. […] Lumbar puncture and testing of cerebrospinal fluid are not indicated in the workup for cerebral venous thrombosis.
#24 Can You Spot Cavernous Sinus Thrombosis? – JournalFeedExpandExpandExpandAccountSearchSearchToggle MenuAccountToggle Menu CloseSearch
https://journalfeed.org/article-a-day/2024/can-you-spot-cavernous-sinus-thrombosis/
Cavernous sinus thrombosis (CST) is a rare but serious thrombophlebitic disease that can be easy to miss in the emergency department setting. This article provides an overview of CST as well as some pearls for clinching this diagnosis for emergency medicine physicians. […] Consider the diagnosis of CST in patients with recent head or neck infection (most commonly sinusitis or an odontogenic infection) who are now presenting with a frontal headache and systemic symptoms such as fever or chills. Most patients will also experience ocular symptoms such as eyelid swelling, photophobia, pain with extraocular movement, or changes to their vision. […] Diagnosis can be confirmed via CT imaging of the orbits and head with delayed IV contrast or magnetic resonance venography (MRV). Laboratory workup should include inflammatory markers and blood cultures. Consider lumbar puncture in patients with concern for meningitis or encephalopathy.
#24 Can You Spot Cavernous Sinus Thrombosis? – JournalFeedExpandExpandExpandAccountSearchSearchToggle MenuAccountToggle Menu CloseSearch
https://journalfeed.org/article-a-day/2024/can-you-spot-cavernous-sinus-thrombosis/
Broad spectrum antibiotics that cover both gram negative and anaerobic bacteria should be promptly administered for patients where this diagnosis is suspected. Some patients will also require treatment with anticoagulation. Consultation with otolaryngology, ophthalmology and possibly neurosurgery is recommended as some patients will require surgical drainage. […] CST is an especially tricky diagnosis to make in the emergency department as these patients often present like many of our other undifferentiated septic patients. After reading this article, I will have heightened suspicion for CST in patients with ocular symptoms or who report symptoms consistent with a head/neck infection within the last month. Interestingly, a CT head without contrast is often unremarkable, which makes me think I should consider a CT with orbits and head with contrast a little more often, especially since laboratory findings may be indeterminate.
#25 Cavernous sinus thrombosis differential diagnosis – wikidoc
https://www.wikidoc.org/index.php/Cavernous_sinus_thrombosis_differential_diagnosis
Cavernous sinus thrombosis must be differentiated from other diseases that cause severe headache, pain with eye movements, high fever, proptosis, periorbital swelling, and ophthalmoplegia, such as orbital cellulitis, acute Angle-Closure Glaucoma, intracranial tumors and, carotid cavernous fistula and tolosa-Hunt syndrome. […] Cavernous sinus thrombosis must be differentiated from other diseases that cause severe headache, pain with eye movements, high fever, proptosis, periorbital swelling, and ophthalmoplegia, such as orbital cellulitis, acute Angle-Closure Glaucoma, intracranial tumors and, carotid cavernous fistula and tolosa-Hunt syndrome.
#26 Cavernous Sinus Thrombosis – emDocs
https://www.emdocs.net/cavernous-sinus-thrombosis/
Antibiotics are primary in the treatment of CST. […] The use of anticoagulation and corticosteroids remains controversial. […] Most authors recommend considering anticoagulation only if there is no evidence of severe bleeding risk or current hemorrhage by history, exam, and imaging. […] Because of the high mortality and devastating consequences of CST, physicians need to keep a high level of suspicion for the condition, image liberally, and administer antibiotics as soon as possible.
#27 Cavernous Sinus Thrombosis: Symptoms, Causes and Treatment | Apollo Hospitals
https://www.apollohospitals.com/diseases-and-conditions/cavernous-sinus-thrombosis-symptoms-causes-and-treatment
Cavernous sinus thrombosis is typically caused due to bacterial infection that spreads from the face and skull. […] After a physical examination and analysis of the medical history, doctors may prescribe the following tests to diagnose the condition accurately: […] MRI and CT scans allow the physician to identify blood clots in the cavernous sinuses. […] In this procedure, the doctor intravenously injects a contrast dye to see the blood flow during the MRI. […] The patients blood and other bodily fluids, including sinus fluid, is tested for pathogens causing infection. […] In this, the doctor inserts a needle into the patients spine to collect a sample of the spinal fluid. […] As cavernous sinus thrombosis is a life-threatening condition that quickly progresses, the doctor may immediately begin treatment before getting an accurate diagnosis.
#28
https://www.nhs.uk/conditions/cavernous-sinus-thrombosis/
Cavernous sinus thrombosis is a blood clot in the cavernous sinuses. It can be life-threatening. […] After an examination, you may be referred for tests, including a CT scan, an MRI scan and blood tests. […] Cavernous sinus thrombosis needs treatment in hospital. […] Antibiotics are the main treatment for cavernous sinus thrombosis. Treatment will be started as soon as possible, even before tests have confirmed if a bacterial infection is responsible. […] You may also be given a medicine called heparin to help dissolve the clot and prevent further clots. […] Some people are also given steroid medicine (corticosteroids). […] If the symptoms of cavernous sinus thrombosis were caused by an infection spreading from a boil or sinusitis, it may be necessary to drain away pus from that site. […] Several weeks of antibiotic treatment are usually necessary to ensure the infection has cleared. However, it can take a long time to recover fully, and it may be several months before you’re well enough to leave hospital.
#29 A Case Report of Cavernous Sinus Thrombosis in a 40-year-old pati
https://www.iomcworld.org/open-access/a-case-report-of-cavernous-sinus-thrombosis-in-a-40yearold-patient-with-adenocarcinoma-of-unknown-primary-origin-93505.html
CT Brain was done to evaluate and confirm the diagnosis of CST. […] The patient received empiric antibiotics and anticoagulants immediately after CT confirmation of CST. […] CST in the setting of malignancy is very rare and there are very few cases reported in the literature. Risks and benefits should be carefully assessed individually while considering anticoagulation as a treatment avenue in patients with malignancy.
#30 Cavernous Sinus Thrombosis as a Complication of Cerebro-Rhino Orbital Mucormycosis Associated With Covid-19: A Case Report
https://www.clinmedjournals.org/articles/ijodh/international-journal-of-oral-and-dental-health-ijodh-8-147.php?jid=ijodh
Cavernous sinus thrombosis is a life-threatening condition that arises as a complication of facial infection, sinusitis, orbital cellulitis, pharyngitis, or otitis of fungal or bacterial origin or after traumatic injury or surgery. […] We present the case of a patient with Cavernous Sinus Thrombosis diagnosed with Rhinocerebral Mucormycosis. […] The diagnosis of cavernous sinus thrombosis is made on clinical grounds, with appropriate radiological imaging to confirm the diagnosis. Magnetic resonance imaging (MRI) is the most sensitive imaging modality; however, contrast-enhanced CT may be preferred as it is easier to obtain, more cost-effective, and effective when it comes to identify the integrity of the bony structures and/or the underlying source of infection. […] Cavernous sinus thrombosis may be difficult to detect by CT or MR imaging in the early phase of the disease, Therefore, astute clinical examination with a high index of suspicion for cavernous sinus thrombosis, supported by known risk factors of diabetes, malignancy and immunosuppression, can lead to a diagnosis.
#31 Cerebral Venous Sinus Thrombosis (CVST) > Fact Sheets > Yale Medicine
https://www.yalemedicine.org/conditions/cerebra-venous-sinus-thrombosis-cvst
Treatment for people who experience CVST following Johnson Johnson vaccination differs from the usual treatment protocols. These patients should not take heparin, as it may be unsafe for the particular type of clot associated with this vaccine. Anyone who experiences headache, stomach pain, leg pain, or shortness of breath within three weeks of receiving the Johnson Johnson vaccine should get in touch with their health care provider.
#32 New recommendations on cerebral venous and dural sinus thrombosis from the German consensus-based (S2k) guideline | Neurological Research and Practice | Full Text
https://neurolrespract.biomedcentral.com/articles/10.1186/s42466-024-00320-9
CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT). […] D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed. […] Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding. […] Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.
#33 Cerebral Venous Sinus Thrombosis (CVST): Causes & Treatment
https://my.clevelandclinic.org/health/diseases/22560-cerebral-venous-sinus-thrombosis
Cerebral venous sinus thrombosis (CVST) is a rare blood clot in one of your brains veins. The outlook is good for those who get a prompt diagnosis and treatment. Prompt diagnosis and treatment give you the best chance of avoiding life-threatening complications. […] Your healthcare provider will use brain imaging to diagnose cerebral venous sinus thrombosis. A prompt diagnosis gives you the best chance of avoiding complications. […] To diagnose cerebral venous sinus thrombosis, your healthcare provider can use imaging, such as brain MRI (magnetic resonance imaging) with contrast (dye). […] The outlook is good for people who get the right diagnosis and treatment for cerebral venous sinus thrombosis. However, CVST can be fatal if you arent diagnosed and treated early.
#34 Cerebral venous sinus thrombosis: review of the demographics, pathophysiology, current diagnosis, and treatment in: Neurosurgical Focus Volume 27 Issue 5 (2009) Journals
https://thejns.org/focus/view/journals/neurosurg-focus/27/5/article-pE3.xml
Cerebral venous sinus thrombosis (CVST) is a rare clinicopathological entity. The clinical picture of CVST is nonspecific, highly variable, and can mimic several other clinical conditions. Diagnosis of CVST is established with the implementation of neuroimaging studies, especially MR imaging and venography. The recent advances in the diagnosis and treatment of patients with CVST have significantly lowered the associated mortality and morbidity and have improved the outcome of these patients. […] Cerebral venous sinus thrombosis demonstrates a highly variable clinical picture, such that the clinical presentation does not offer significant help in establishing the diagnosis. The nonspecific clinical presentation and its importance in making the diagnosis of CVST are reflected in the results of the ISCVT study, in which the median delay from the onset of symptoms to the diagnosis was 7 days. The differentiation between arterial stroke and CVST should rely on specific characteristics of these 2 distinct clinicopathological entities. The extensive and highly variable spectrum of clinical presentation in CVST cannot establish its diagnosis in the majority of the cases; therefore, neuroimaging studies are of paramount importance.
#34 Cerebral venous sinus thrombosis: review of the demographics, pathophysiology, current diagnosis, and treatment in: Neurosurgical Focus Volume 27 Issue 5 (2009) Journals
https://thejns.org/focus/view/journals/neurosurg-focus/27/5/article-pE3.xml
The initial imaging study in the evaluation of patients with possible CVST is usually a brain CT scan. Magnetic resonance imaging, as well as MR angiography and venography, provide us with the most sensitive tools for detecting CVST. The combination of these imaging modalities constitutes the study of choice in the diagnosis of CVST. Despite the well-documented high sensitivity and specificity of MR imaging and MR venography in diagnosing CVST, there are a few reports in the literature of misdiagnosis due to MR imaging flow artifacts. […] A thrombophilia check-up (antithrombin III, factor V Leiden, protein C and protein S levels, as well as prothrombin time, aPPT, and platelet count and functionality) should be routinely checked in patients suffering from CVST. The nonspecific and often misleading clinical presentation of CVST, along with the existence of no pathognomonic laboratory tests that can rule out CVST, makes the establishment of its diagnosis quite challenging.
#35 Cavernous Sinus Thrombosis – Diagnosis and Treatment – County EM
http://blog.clinicalmonster.com/2017/12/21/congested-picked-nose-developed-cavernous-sinus-thrombosis/
Cavernous sinus thrombosis (CST) is a rare condition caused by a blood clot in the cavernous sinus. The thrombosis can be septic or aseptic. Aseptic CST follows surgery or trauma but is far less common than septic CST. Septic CST occurs when an embolus infected with bacteria or fungus reaches the cavernous sinus through its many anastomotic connections. […] The estimated annual incidence of cavernous sinus thrombosis is approximately 0.2 to 1.6 per 100,000 per year. […] The typical patient may endorse a recent history of sinusitis or a facial furuncle that he or she tried to pop at home in the week or two prior to presentation. […] Emergency physicians should have a low threshold to workup CST because any delay can lead to significant morbidity and mortality. The constellation of symptoms above along with imaging can confirm the diagnosis.
#36 Septic cavernous sinus thrombosis – UpToDate
https://www.uptodate.com/contents/septic-cavernous-sinus-thrombosis
Septic cavernous sinus thrombosis is an uncommon condition with only several hundred cases reported in the English medical literature during the antibiotic era. Since this disorder is rare, each clinician is likely to encounter only one or a few cases during his or her career. The combination of lack of familiarity and the myriad of potential symptoms and signs often leads to misinterpretation of the clinical manifestations. […] The cavernous sinus is the most frequent dural venous sinus to become infected and thrombosed, producing headache along with swelling around the eye and cranial nerve deficits. […] This topic discusses septic cavernous sinus thrombosis. Septic dural sinus thrombosis affecting other sites and aseptic dural sinus thrombosis are discussed separately.
#37 Cavernous Sinus Thrombosis: Causes, Symptoms And Treatment
https://www.netmeds.com/health-library/post/cavernous-sinus-thrombosis-causes-symptoms-and-treatment?srsltid=AfmBOoqa009PpQzR83N6P5BarUe8veyMqoTkSm5rVTPrmr2_RKs0Dd_A
Cavernous sinus thrombosis is a rare ailment characterised by blood clots in the cavernous sinuses, that can prove to be fatal if left unattended. […] Thus, it is necessary to understand the causes, symptoms, complications of cavernous sinus thrombosis, to provide timely medical diagnosis and treatment, to rectify the perilous condition in the patient. […] The physician records the complete medical history of the patient, besides taking note of any recent infections encountered by them. To verify the presence of an internal blood clot, the healthcare provider carries out imaging analyses of the sinuses, like MRI and CT scans. A sample of blood is also collected from the patient and studied under a microscope to determine if any bacterial strains are present that are causing the infection and blood clots in the cavernous sinuses. […] Promptly reporting the symptoms to a doctor, followed by precise diagnosis and professional medical aid in a hospital ensure the halt of infection spread within the body and help the affected patient recover well.