Cavernous sinus thrombosis pathophysiology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Pathophysiology

The cavernous sinus which is a true dural venous sinus, is irregularly shaped, trabeculated cavities in the base of the skull.

The cavernous sinus receives blood via the superior and inferior ophthalmic veins through the:

• Superior orbital fissure
• Superficial cortical veins

Cavernous sinus is connected to the basilar plexus of veins posteriorly.

There are some important nerves and arteries pass through the cavernous sinus, include:

• The internal carotid artery (carotid siphon)
• Cranial nerve III
• Cranial nerve IV
• Cranial nerve V branches:
  • Branch V₁
  • Branch V₂
• Cranial nerve VII

Infection from the face may reach the cavernous sinus through its many anastomotic connections, with severe consequences. The cavernous sinus drains by two larger channels, the superior and inferior petrosal sinuses, ultimately into the internal jugular vein via the sigmoid sinus, also draining with emissary vein to pterygoid plexus. These sinuses are just lateral and superior to the sphenoid sinus and are immediately posterior to the optic chiasm. Each cavernous sinus is formed between layers of the dura mater, and multiple connections exist between the 2 sinuses.

Pathogenesis

• It is understood that the main cause of cavernous sinus thrombosis is bacterial infections.
  • Staphylococcus aureus may account for two-thirds of cases of cavernous sinus thrombosis.
  • Other typical organisms include:
    • Streptococcus species (approximately 20% of cases)
    • Pneumococcus (5%)
    • Gram-negative species such as Proteus
    • Hemophilus
    • Pseudomonas
    • Fusobacterium
    • Bacteroides
    • Gram-positive species such as Corynebacterium and Actinomyces

• In cavernous sinus thrombosis, a blood clot develops in the sinus cavernous structure to prevent the infection from spreading to brain, but it often blocks the blood flow out of the brain.

• Septic cases of cavernous sinus thrombosis are usually caused by central facial infections, especially within the danger triangle of the face (from the corners of the mouth to the bridge of the nose.
• The main sources of infection include:
  • Mastoiditis
  • Otitis media
  • Abscess
  • Cellulitis
  • Sinusitis
  • Dental infections or procedures (even a posterior superior alveolar nerve block entering the pterygoid plexus)
  • Maxillofacial surgery

• The other rare causes of cavernous sinus thrombosis include:
  • Fungal infections
  • Severe head injuries
  • Autoimmune conditions such as lupus
  • Pregnancy