Neurosurgery notes/Anatomy/Vascular/Veins/Cavernous sinus/Cavernous sinus syndrome (CSS)

Cavernous sinus syndrome (CSS)

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Parent item
Cavernous sinus
Sub-item
Tolosa Hunt syndrome
  • Is a condition caused by any pathology involving the cavernous sinus which may present as a combination of
    • Unilateral ophthalmoplegia (cranial nerve (CN) III, IV, VI) OR
    • Autonomic dysfunction (Horner syndrome) OR
    • Sensory CN V1- CN V2 loss.
  • Aetiology
      • Cause
      Clinical Features
      Tumor
      Meningioma, chordoma, neuroma, pituitary adenoma, metastases, lymphoma, nasopharyngeal carcinoma, chondrosarcoma, hemangioma, neuroblastoma
      Inflammatory
      Tolosa-Hunt syndrome, sarcoidosis
      Trauma
      Basal skull fracture, operative trauma to cavernous sinus after skull base surgery
      Vascular
      Intracavernous aneurysm, carotid-cavernous fistula, cavernous sinus thrombosis
      Infection
      Mucormycosis, aspergillosis, actinomycosis, nocardiosis, mycobacterium, herpes zoster
  • Mechanism
    • Compression and dysfunction of the structures within the cavernous sinus
  • Clinical presentation
    • Parkinson sign
      • Horner + CN VI palsy
      • Due to damage to the postganglionic sympathetic plexus travelling on the ICA and CN VI
    • Total/partial ophthalmoplegia
      • CN III palsy – partial or total loss of elevation, depression and adduction of ipsilateral eye
      • CN IV palsy – partial or total loss of abduction and depression of ipsilateral eye
      • CN VI palsy – partial or total loss of abduction of ipsilateral eye
    • Facial sensory loss
      • CN V1 loss – partial or total loss of sensation in ophthalmic distribution
      • CN V2 loss – partial or total loss of sensation in maxillary distribution
    • Horner syndrome
      • Loss of sympathetic tone due to damage of sympathetic plexus
    • Proptosis and chemosis
      • Due to increased pressure within cavernous sinus
    • Presence of fever, tachycardia, hypotension, rigors, nuchal rigidity, altered mental status should cause concern for CS-Thrombosis
  • Investigation
    • Bloods
      • FBC
      • Blood cultures, ? infection.
      • Serum studies ESR, CRP, angiotensin converting enzyme (ACE), and antineutrophil cytoplasmic antibodies (ANCA)
    • Radiology
      • MRI brain + orbits with contrast + MRV
        • Presence of a tumor, trauma, inflammation, or CST.
      • CT brain and orbits + CTV
        • Presence of trauma or vascular process