CAVERNOUS SINUS

Surgical anatomy and Cavernous Sinus

Thrombosis

Dr. Mukhallat Qazi

1st Year Postgraduate
Department of OMFS

OVERVIEW
Introduction
Development
Anatomy
o
o

Structures within
Structures
around
Tributaries

Cavernous Sinus
Thrombosis
o

o
o
o
o

Clinical
Presentation
Danger Area of the
Face
Investigations
Neuroradiology
Complications
Treatment

INTRODUCTION
The space or compartment commonly called the
cavernous sinus is a veritable anatomical jewel box
containing more significant structures than any
other comparable space outside the brain itself.
(Parkinson 1990)
Cavernous+ Sinus
Cavernous- Cavern: A large cave or chamber in a cave
specific type of cave, naturally formed in soluble rock with the
ability to grow speleothems
3

Sinus- Medieval Latin: A hollow curve or cavity in the body

 Called Circular sinus" by Ridley (1695)

Wilson(1732)
Named this structure CAVERNOUS SINUS Due to its spongious structure
which seemed to be formed by numerous fibres and connective tissue septae

Dural Sinuses
Lie between the endosteal and meningeal
layers of dura mater
Are lined by endothelium, firm collagenous
tissue
Have no valves
Walls are devoid of muscular tissue
Numerous lacunes and trabeculae
5

DEVELOPMENT
Padget (1956)
Cavernous sinus Plexiform extension of prootic
sinus and ventral myelencephalic vein
Superior ophthalmic v Primitive maxillary v as
it drains into the prootic sinus, and develops into
the superior ophthalmic vein which drains
directly into the cavernous sinus.
7

40 mm

60 mm

3rd
month

Adult

Plexiform extension of prootic sinus

Ventral portion of myelencephalic vein

Cavernous sinus which receives only ophthalmic veins

Drains into the Inf. Petrosal sinus, ultimately the IJV

Cavernous sinus and Inf petrosal Sinus do not receive Cerebral

Venous drainage

Cavernous Sinus receives SMCV, Sphenoparietal Sinus

Drains into the IPS, SPS, Pterygoid Plexus
8

 Knosp (1987)
20% of fetal skull bases- SMCV drains into the
Cavernous Sinus
60% of fetal skull bases- SPS and Cavernous
Sinus show a connection
Hence developmental basis for varied pattern of
venous tributaries and drainage
9

Schematic drawings of the developmental anatomy of cavernous and

para-cavernous venous structures in the embryonic stage.

S. Tanoue et al. AJNR Am J Neuroradiol 2006;27:1083-1089

2006 by American Society of Neuroradiology

ANATOMY
Number
2, Paired
Dimensions
Length 20mm
Width 09mm
Location
Middle Cranial Fossa
Either side of body of
sphenoid
Extent
From Superior Orbital
Fissure to the Petrous apex of
Temporal bone
Shape
Triangular in cross section,
Boat shaped

11

12

STRUCTURES WITHIN..
CONTENTS
Cavernous
Sinus

Central
Structures

Lateral wall

culomoto
rn
CN3

Trochlear n
CN4

Maxillary n
CN V2

Ophthalmic
n
CN V1

ICA

Abducens n
CN 6

13

14

Anatomical Relations
Osseou
s
Relatio
ns

Dural
Relatio
ns

Caverno
us sinus
Vascul
ar
Relatio
ns

Neural
Relatio
ns

15

16

Osseous Relations
ANTERIO
R

MEDIA
L

LATERA
L

Optic
strut

Caroticoclinoid
foramen

Greater
wing of
sphenoid

Anterior
clinoid
process

Middle
clinoid
process

Foramina

Lesser
wing of
sphenoid

Pituitary
fossa
Body of
sphenoid
Carotid
sulcus

(rotundu
m, ovale,
spinosu
m)

POSTERIOR

Posterior
Cliniod
Process
Dorsum
Sella
Petrous
Apex
Trigemin
al
Impressi
on

17

18

Ant Clin Process

Carotid sulcus- Course of ICA
Optic Strut- Lateral and
inferior wall of the optic canal
These three structures almost
encircle the ICA

19

CLINICAL SIGNIFICANCE OF
OSSEOUS RELATIONS
In surgically exploring cavernous sinus, an
initial step is to unlock the contents of the
sinus from the bony confines.
This step includes unroofing and mobilizing the
optic nerve, and then removing anterior clinoid
process.
This phase can be performed in an extradural or
intradural fashion.

DURAL RELATIONS
Superior

Inferior

Dura Mater
Tentorium
Cerebelli

Periosteum
floor

Medial

Lateral

Endosteum
of Sella
turcicas
Lateral
wall

Dura
Propria of
uncus of
temporal
lobe

ROOF
Anterior extension of
the Tentorium
Cerebelli
Lateral extension of
Diaphragma Sella

22

Posterior
Wall
Lower
margin
shared with
basilar
sinus,
pierced by
Abducens n
Upper edgeposterior
petroclinoid
al fold

23

Medial Wall
Dura covering
the lateral
aspect of the
Sella turcica
and the lateral
surface of
body of
Sphenoid bone
24

Lateral
wall
Dura
propria of
Uncus of
the
temporal
lobe
25

26

Upper and lower dural rings

Upp Upper
margin of
er
anterior
dura clinoid
l ring process
Low Lower
margin of
er
anterior
dura clinoid
l ring process
The segment of the internal carotid artery located between the upper and
lower dural rings, which is exposed by removing the anterior clinoid
process, is referred to as the clinoid segment.

27

NEURAL RELATIONS
Cranial nerves III to VI are closely related to cavernous sinus.

Oculomotor Nerve
CN III
Courses
lateral to
PCP

Exits
through
SOF

Enters
Cavernous
sinus on
superolateral
surface

Passes along
inferolateral
surface of
ACP

Passes lateral
to the
cavernous
sinus

Here its
epineurium
interweaves
with that of
CN IV

29

After exiting through SOF,

between the heads of the
lateral rectus muscle

Superior
division

Levator
Palpebrae
Superioris

Superior
Rectus

Inferior
Division

Medial and
inferior
recti

Inferior
Oblique

30

Trochlear Nerve
Trochlear nerve enters the roof
of the sinus posterolateral to
the oculomotor nerve

Courses below the oculomotor

nerve in the posterior part of
the lateral wall.
Anteriorly, below the base of
the anterior clinoid process, it
passes upward along the
lateral surface of the
oculomotor nerve.
Passes medially between the
oculomotor nerve and anterior
clinoid and optic strut

Reaches the medial part of the

orbit and the superior oblique
muscle.

31

Ophthalmic Nerve

32

33

Abducens Nerve
The abducens nerve pierces the dura
Forms lower part of the posterior wall of the
sinus
At the upper border of the petrous apex,
enters Dorellos canal

Passes below the petrosphenoid ligament

(Grubers ligament)

Bends laterally around the intercavernous

carotid
Passes forward, medial to the ophthalmic
nerve, on the lateral side of the internal
carotid artery.

Exit through the SOF

and supplies the
Superior Oblique m

34

Clinical Significance
Cranial nerve palsy is the most common manifestation of
pathologic processes involving the cavernous sinus.
Diplopia, Sixth nerve palsy with Horners Syndrome, impaired
visual acuity may suggest cavernous sinus lesions.
Most cavernous sinus explorations are for benign disease
with the goal of preserving and improving cranial nerve
function.
Exploration of cavernous sinus usually follows mobilization of
lateral wall and entry through one or more of the various
triangles formed by these cranial nerves and dural folds.

35

Anatomic Triangles

Vascular Relations
Arterial Relations
Internal Carotid
Artery and its
anatomically
divided course Petrous
Cavernous
Intracranial

Venous
Relations
Afferent
Tributaries
Efferent
Drainage
37

Internal carotid artery

38

Initially runs
vertically,
becomes
horizontal in
Petrous
part
the
petrous
temporal bone
(C2)
POSTERIOR
LOOP

Crosses For.
Lacerum under
Trigeminal
ganglion

Ascends
towards
Cavernous
Sinus (C3)
LATERAL LOOP

39

Enters
cavernou
s sinus
through
the
posterior
aspect

Ascends
towards
Posterior
Clinoid
Process

Becomes
Horizonta
l (C4)
MEDIAL
LOOP

After
horizonta
l course
through
sinus, it
reverses
its
course

Reaches
towards
lateral
aspect of
ACP
Exits
from
sinus
(C5)
ANTERIO
R LOOP

Anterior
loop is
oriented
at 30
degrees
to the
horizonta
l plane

40

41

Inferior
hypopheseal
Meningohypophys
eal trunk from C5
Intracranial
ICA
In the
cavernous
segment

Tentorial
Clival (Dorsal
Meningeal

Inferolateral
Trunk (Inf Cav
Artery to CN
Sin Br.) from
3,4,6
C4
Mc Connells
Sella turcica,
Capsular Artery from
roof and floor
C4
42

Veinous relations
Tributaries (afferent
veins):
Superior ophthalmic vein
(SOV)
Inferior ophthalmic vein
(IOV)
Central retinal vein
Superficial middle cerebral
vein (SMCV)
Uncal vein (UV)
Sphenoparietal sinus (SPPS)
Meningeal veins

43

Drainage (efferent
veins):
Foramen ovale plexus (FOP)
Vein of the foramen
rotundum
Pterygoid plexus (PP)
Internal jugular vein (IJV)
Facial vein (FV)
Angular vein (AV)
Retromandibular vein
Supraorbital vein
Frontal vein (FrV)

44

 Basilar plexus (BP)

Sphenoparietal sinus
(SPPS)
Sigmoid sinus (SS)
Superior petrosal
sinus (SPS)
Inferior petrosal
sinus (IPS)
Intercavernous sinus
(ICS)
Jugular bulb (JB)
Middle temporal vein
(MTV)

45

46

COMMUNICATIONS OF
CAVERNOUS SINUS
Venous blood from the brain flows via the superficial( cortical)
and the deep cerebral veins into the venous (dural) sinuses.
There are numerous connections between the cortical veins
and dural sinuses.
This facilitates the spread of thrombus infection between
these vessels.
Also allows opening of collateral draining vessels in the event
of an occlusion.

Summary of communication
The cavernous sinuses receive blood from
cerebral veins
the ophthalmic veins (from the orbit)
emissary veins (from the pterygoid plexus of veins in the infratemporal
fossa).

These connections provide pathways for infections to pass

from extracranial sites into intracranial locations. In addition,
because structures pass through the cavernous sinuses and
are located in the walls of these sinuses, they are vulnerable
to injury due to inflammation.

49

Clinical significance of Vascular

Relations
Lesion of surgical importance affecting ICA range from
aneurysm to carotid-cavernous fistulae.
After removal of anterior clinoid process, mobilization of
anterior loop of ICA can be done for clipping of aneurysm.
Treatment of aneurysm ranges from simple observation to
balloon occlusion and trapping of the lesion with or without
bypass.

Conditions affecting Cavernous

sinus and its contents

Midbrain Infection
Cavernous Sinus Thrombosis
Orbital Fracture
Petrous Bone Fracture (Temporal bone Fracture )
Internal Carotid Artery Aneurysm
Mastoiditis
Increased Intracranial Pressure

Clinical and applied aspects

It is the only anatomic location in the body in which an
artery travels completely through a venous structure. If
the internal carotid artery ruptures within the cavernous
sinus, an atriovenous fistula is created.
Cavernous sinus syndrome may result from mass
effect from a tumour or CST and cause opthalmoplegia
from compression of the oculomotor nerve, trochlear
nerve, and abducens nerve, ophthalmic sensory loss
from compression of the ophthalmic nerve, and maxillary
sensory loss from compression of the maxillary nerve.
Cavernous sinus thrombosis is the formation of a
blood clot within the cavernous sinus.

Emissary Veins
Emissary Syn.
ambassador
From skull veins to
external veins
Importance- to maintain
intracranial and
extracranial venous
pressure at an equilibrium,
valve-less to ensure the
same.
May carry Infected
thrombus from
extracranial to intracranial

53

CAVERNOUS SINUS
THROMBOSIS
Thrombosis of the cavernous sinus is one of the most
dramatic of neuro-ophthalmic conditions.
Within a short period, a swollen orbit, limited ocular
motility and impaired vision develop, and may progress
to a life threatening condition
Rapid diagnosis and therapeutic action are required.
Morbidity is high, and outcome cannot be certain.
54

Epidemiology

Frequency:

In the US occurrence of CST has always been low, with

only a few hundred case reports in the medical literature. The majority
of these date from before the modern antibiotic era. One review of the
English language found only 88 cases from 1940 -1988.

Mortality/ morbidity:

Prior to the advent of affective antimicrobial agents, the

mortality rate from CST was effectively 100%. Typically death is due to
sepsis or central nervous system infection. With aggressive
management the mortality rate is now less than 30%. Morbidity
however remains high and complete recovery is rare. Roughly one sixth
of patients are left with some degree of visual impairment and one half
have cranial nerve deficits.

Race : no predilection

Sex: no predilection

Age : all ages are affected with a mean of 22 years

55

Causes of cavernous sinus

thrombosis
Mid face infection/ cellulitis
PNS infection (Ethmoid or Sphenoid
Sinuses)
Odontogenic infections
Orbital Cellulitis
Septicemia

Danger area of the face

The cavernous
sinus
communicates
with dangerous
area of face
through 2 routes
Deep facial
Angular vein
veins, pterygoid
Superior
plexus of veins,
ophthalmic vein
emissary vein.
57

Odontogenic origin of CVT

CST is one of the major complications resulting from
infection of teeth or surrounding structures in the upper
and lower jaws.
Extraction of mandibular molars (Buccal Space) and
maxillary anterior teeth (Infraorbital Space) in the
presence of acute infection, usually staphylococcal, can
cause this condition.
The infection can spread by
Direct
Hematogenous(metastatic )

Direct Spread
Spread by direct extension via
the infratemporal space
through the cranial wall
By way of pterygoid plexus and
emissary veins, against the
usual flow.
This is possible because of the
anatomic anomaly of the
absence of valves in the

angular, facial and

ophthalmic veins.
Staphylococcus aureus
More often from upper teeth
than lower teeth.

Heamatogenous
Spread

More often from lower

teeth than upper teeth
Reverse of direct spread.
Streptococcus
(haemolytic, nonhemolytic, or viridans)
usually associated
59

Method of spread into cranial

cavity
Infection of the upper lip, spread by way of the angular,
supraorbital and supratrochlear veins to
vestibule of the nose and
the ophthalmic veins. Commonest route
eyelids
of infection.

Intranasal operations on
through the ethmoidal veins.
the septum, turbinates or
ethmoid/ sphenoid sinus
infection
Operations on the tonsil,
peritonsillar abscess, surgery spread by pterygoid plexus or by direct
or osteomyelitis of the
extension to the internal jugular vein.
maxilla, dental extraction
and deep cervical abscess

Involvement of the middle

retrograde spread through the petrosal
ear and mastoid with
sinuses to the cavernous sinus.
lateral sinus phlebitis or
thrombosis

Ptosis

Proptosis

Chemosis

62

Clinical history
Patient generally have sinusitis or a midface infection
(most commonly a furuncle) for 5-10 days. In as many
as 25% of cases in which a furuncle is the precipitant, it
will have been manipulated in some fashion(eg:
squeezing, surgical incision.)
Headache, fever, and malaise typically precede the
development of ocular findings. As the infection tracts
posteriorly, patient complains of orbital pain and
fullness accompanied by periorbital edema and visual
disturbances.
In some patients, periorbital findings do not develop
early on and the clinical picture is subtle.

 Without effective therapy, signs appear in the

contralateral eye by spreading through the
communicating veins to the contralateral cavernous
sinus. This is pathognomic for CST.
The patient rapidly develops mental status changes
from CNS involvement and/or sepsis.
If not treated promptly, death follows thereafter.

Other typical finding

Initially signs of venous congestion may be present.
Chemosis
Eyelid edema
Periorbital edema
Manifestation of increased retrobulbar pressure
Exophthalmos
Opthalmoplegia

 Signs of increased intraocular pressure may be

observed
Pupillary responses are sluggish
Decreased visual acuity is common owing to
increased iop and traction on the optic nerve
and central retinal artery.
Cranial nerve palsies are found regularly
Isolated sixth nerve dysfunction may be noted
before obvious orbital findings.
Extraocular movements may be impaired.
Depressed corneal reflex is possibly seen.

 Appearance of signs and symptoms in the

contralateral eye is diagnostic of CST, although
the process may remain confined to one eye.

Meningeal signs may be noted, including nuchal

rigidity and Kernig and Brudzinski signs.

Systemic signs indicative of sepsis are late

findings. They include chills, fever, shock,
delirium, and coma.

68

Eagletons diagnostic criteria

In 1926 Eagleton suggested 6 criteria which are
now considered as the guidelines for diagnosis
1. A known site of infection
2. Septicemia
3. Early signs of venous congestion
4. Ocular, maxillary, abducent nerve deficits
5. Abscess or phlebitis contagious to cavernous
sinus
6. Symptoms of complicated disease

Etiology
Staphylococcus aureus is the most common
infectious microbe, found in 50% to 60% of the
cases. Streptococcus pneumoniae is the second
leading cause.
Gram-negative rods and anaerobes may also
lead to cavernous sinus thrombosis.
Rarely, Aspergillus fumigatus, Mucormycosis,
Haemophilus influenzae cause CST.

BACTERIOLOGY
Children

H. influenzae
Staph. aureus
Strep. Pneumoniae

Adults

Mixed infections
Aerobes
Anaerobes
Bacteroides
Veillonella
Peptostreptococci
Strep. milleri
Strep. constellatus

Complications
Intracranial extension of infection may result in
meningitis, encephalitis, brain abscess,
pituitary infection, and epidural and subdural
empyema.
Cortical vein thrombosis can result in
hemorrhagic infarction.
Extension of the thrombus to other sinuses can
occur.

CST

Increased
venous
congestion
Increased
venous sinus
&CSF pressure
Cerebral
haemorrhage
& infraction

Systemic
embolism

Hypopituitaris
m

Pulmonary
embolism
(10-20%)

73

Diagnosis and imaging

Cavernous sinus on MRI

Differential Diagnosis
Orbital cellulitis

Intraorbital abscess
Intracavernous carotid artery aneurysm or Arteriovenous
fistulae
Idiopathic granulomatous inflammation of the superior orbital
fissure and cavernous sinus(Tolosa-Hunt syndrome)
Periarteritis nodosa associated with cavernous sinus
thrombosis (Cogans syndrome)
Nasopharyngeal tumor
Meningeoma
Trauma

MANAGEMENT OF CAVERNOUS SINUS

THROMBOSIS
The mainstay of therapy is early and aggressive
antibiotic administration.
AlthoughS aureusis the usual cause, broad-spectrum
coverage for gram-positive, gram-negative,
andanaerobicorganisms should be instituted pending
the outcome of cultures.
Empiric antibiotic therapy shouldincludea
penicillinase-resistant penicillin plus a third
generationcephalosporin.
Vancomycin may be added for MRSA.
IV antibiotics are recommended for a minimum of 3-4
weeks.

Antibiotic therapy:
Oxacillin

Ceftriaxone

Metronidazole

Bactericidal antibiotic inhibiting cell wall synthesis

Used in treatment of infections caused by
penicillinase producing staphylococci

Alternate antimicrobial choice

3rd generation cephalosporin that has broad gram
negative spectrum, lower efficiency against gram
positive organisms than earlier generation
cephalosporin.
Additional anaerobic coverage
Imidazole ring based antibiotic active against various
anaerobic bacteria and protozoa.
Usually employed in combination with other
antimicrobial agents

Binds to 50s bacterial ribosomal subunits and inhibits

bacterial growth by inhibiting protein synthesis
Chloramphenicol Effective against gram negative and gram positive
bacteria

80

Anticoagulant therapy:
Augments activity of antithrombin III and prevents
conversion of fibrinogen to fibrin.
Does not actively lyse thrombus but inhibits further
thrombogenesis.
Prevents re-accumulation of clot after spontaneous
fibrinolysis.

Corticosteroid therapy:
Corticosteroids may help to reduce inflammation and
edema and should be considered as an adjunctive
therapy.
These agents have anti inflammatory properties and
cause profound and varied metabolic effects. When the
course of CST leads to pituitary insufficiency,
corticosteroids definitely are indicated to prevent adrenal
crisis.

82

 Mannitol: osmotic diuretic. Reduces elevated pressure

in brain and eye.

Surgery on the cavernous sinus is technically

difficult and has never been shown to be helpful.
The primary source of infection should be drained,
if feasible.

Prognosis
Following the acute phase of infection, recovery is
gradual
Up to 50% of patients can have long-term neurological
deficits in the form of decreased visual acuity, diplopia,
cranial nerve deficits, hemiparesis, ataxia or epilepsy.
The majority of reported cranial nerve deficits have
involved the occulomotor and abducens nerves. Longterm follow-up of these patients is essential as relapses
have been reported after apparent clinical resolution.
Recent studies have shown a mortality rate closer to
10%

CONCLUSION

85

REFERENCES

Grays anatomy
Cavernous Sinus- Developments and future perspectibes- Vinko Dolenc
Neelima Malik 3rd edition
Oral and Maxillofacial infections; Laskin
Contemporary oral and maxillofacial surgery ; Peterson
Operative neurosurgical techniques; Henry Schmidek
Complications of head and neck surgery; Krespi and Ossoff
Anatomy for surgeons: The head and Neck, vol 1; hollinshead
Maxillofacial infections ; Topazian, 4 th edition
Brains diseases of nervous system 10 th edition; John Walton
Color atlas of clinical neurology 2 nd edition; Malcom Parson
Cavernous sinus thrombosis and blindness as complications of an
odontogenic infection; J Oral Maxillofac Surg 47 1317-1321,1989
Ocular manifestations of cavernous sinus thrombosis- V Visvanathan, S
Uppal, S Prowse; BMJ Case Reports 2010

86

THANK YOU!!

87