Тромбоз печеристого синуса

The cavernous sinuses are trabeculated sinuses located at the base of the skull that drain venous blood from facial veins. Cavernous sinus thrombosis is an extremely rare complication of common facial infections, most notably nasal furuncles, sphenoidal or ethmoidal sinusitis (greater than 50%), and dental infections (1). Most common pathogens are Staphylococcus aureus (70%), followed by Streptococcus species; anaerobes are more common when the underlying condition is dental or sinus infection.

Thrombosis of the lateral sinus (related to mastoiditis) and thrombosis of the superior sagittal sinus (related to bacterial meningitis) occur but are rarer than cavernous sinus thrombosis.

The 3rd, 4th, and 6th cranial nerves and the ophthalmic and maxillary branches of the 5th cranial nerve are adjacent to the cavernous sinus and are commonly affected in cavernous sinus thrombosis. Complications of cavernous sinus thrombosis include meningoencephalitis, brain abscess, stroke, blindness, and pituitary insufficiency.

Initial symptoms of cavernous sinus thrombosis are progressively severe headache or facial pain, usually unilateral and localized to retro-orbital and frontal regions. High fever is common. Later, ophthalmoplegia (typically the 6th cranial nerve in the initial stage, which may be associated with Horner syndrome), proptosis, and eyelid edema develop and often become bilateral. Facial sensation may be diminished or absent due to trigeminal nerve involvement. Decreased level of consciousness, confusion, seizures, and focal neurologic deficits are signs of central nervous system (CNS) spread. Patients with cavernous sinus thrombosis may also have anisocoria or mydriasis (3rd cranial nerve dysfunction), papilledema, and vision loss.

• MRI or CT

Cavernous sinus thrombosis is often misdiagnosed because it is rare. It should be considered in patients who have signs consistent with orbital cellulitis. Features that distinguish cavernous sinus thrombosis from orbital cellulitis include cranial nerve dysfunction, bilateral eye involvement, and mental status changes.

Diagnosis is based on neuroimaging. MRI is the better study (1), but CT is also helpful. Contrast-enhanced MR venogram (MRV) and CT venogram are more sensitive than either CT or MRI. Useful adjunct testing may include blood cultures and lumbar puncture (1).

• IV high-dose antibiotics

• Sometimes corticosteroids

• Sometimes anticoagulation

Initial antibiotics for patients with cavernous sinus thrombosis include, eg, nafcillin or oxacillin 1 to 2 g every 4 hours combined with a third-generation cephalosporin (eg, ceftriaxone 1 g every 12 hours). In areas where methicillin-resistant S. aureus is prevalent, vancomycin 1 g IV every 12 hours should be substituted for nafcillin or oxacillin. An antimicrobial for anaerobes (eg, metronidazole 500 mg every 8 hours) should be added if an underlying sinusitis or dental infection is present (1, 2).

In cases with underlying sphenoid sinusitis, surgical sinus drainage is indicated, especially if there is no clinical response to antibiotics within 24 hours.

Secondary treatment for cavernous sinus thrombosis may include corticosteroids (eg, dexamethasone 10 mg IV or orally every 6 hours) for cranial nerve dysfunction. Anticoagulation is controversial; unfractionated and low-molecular-weight heparin have been used in patients without contraindications. These drugs may reduce morbidity, but evidence establishing their efficacy in reducing mortality will require further study (3).

Mortality in the antibiotic era is up to approximately 15%. Approximately one-third more patients develop serious sequelae (eg, ophthalmoplegia, blindness); stroke and pituitary insufficiency are also possible, and deficits may be permanent (1).