Cavernous Sinus Syndrome Dr Hani Hasan Specialty Doctor in Ophthalmology

Demographics Gender: Female Age: 57 years

Presenting symptoms Double vision 3 months Headache 2 months

Summary of presenting illness This lady was first seen in the eye clinic in January 2015because of double vision. During the examination she was found to have prominent episcleral vessels and dilated tortuous retinal vessels in the temporal fundus of the left eye.

Summary of presenting illness A CT orbit was requested, a Fresnel prism was fitted and the patient was given a six weeks follow up period. Visual acuity was 6/5 in both eyes

Summary of presenting illness A month later she was seen as an emergency in the eye casualty. Presented with: Severe frontal headache. Left sided facial asymmetry. Altered taste and smell sensation. Whooshing tinnitus. Examination showed: Reduced sensation to pin prick on the left side of the face. Left RAPD. A significantly increased IOP in the left eye. No change in visual acuity.

Summary of presenting illness Bloods and CXR were unremarkable. A CTPA was requested to exclude a cavernous - carotid fistula, the scan showed complete occlusion of the left internal carotid artery. No aneurysm or fistula seen. An MRI with contrast was requested.

Summary of presenting illness The MRI showed a soft tissue mass in the left cavernous sinus and left Meckel’s cave with extension to the dura over the left sphenoid wing. The post-contrast images revealed slight enhancement involving the left trigeminal nerve in its cisternal segment.

Summary of presenting illness An urgent neurosurgical review was requested. A CT chest, abdomen and pelvis was obtained, it showed multifocal nodular changes in the left lobe of the thyroid gland mainly involving the lower pole. The rest of the scans were unremarkable.

Summary of presenting illness During the following two months the left sixth nerve palsy improved. Involvement of the trigeminal nerve persisted.

Past medical and surgical history Arthritis of the cervical vertebrae. Fibromyalgia rheumatica.

Family history No history of a similar condition. No history of thyroid disease.

Medications and allergies On regular: Tramadol Amitriptyline Gabapentin No known allergies

Summary A 57 year-old female presented with progressive neurological signs and symptoms in the form of: Left 6th and 7th nerves palsy. Left trigeminal neuralgia. was found to have an occluded left internal carotid artery. Further investigation revealed a left cavernous sinus tumor with a possible thyroid tumor as a primary source.

Diagnosis Left Cavernous Sinus Syndrome.

Discussion

Cavernous sinus syndrome Causes: Neoplasia Infections Inflammation Vascular lesions

Anatomy Internal carotid Oculomotor N. Trochlear N. V1 Ophth. division V 2 Maxillary Abducens nerve Pituitary Sympa. plexus

Clinical presentation Impairment of ocular motor nerves. Horner's syndrome. Sensory loss of the first or second divisions of the trigeminal nerve.

Clinical presentation The pupil may be involved or spared or may appear spared with concomitant oculosympathetic and parasympathetic involvement. Various degrees of pain may be involved.

Neoplastic causes Primaries: Secondaries: Meningioma Neurogenic tumors Haemangioma Secondaries: Direct invasion: e.g. Pituitary adenoma Perineural spread: e.g. Head and neck tumors Haematogenous spread: e.g. Other systemic tumors

E.g. Cavernous sinus tumors

Conclusion Cavernous sinus syndrome can be caused by various disease entities. Understanding the characteristic clinical features and their implications as well as the characteristic imaging findings will assist in the differential diagnosis. CT and CTA can miss the primary pathology.

References Cavernous Sinus Syndrome: Clinical Features and Differential Diagnosis with MR Imaging Jeong Hyun Lee, Ho Kyu Lee, Ji Kang Park, Choong Gon Choi and Dae Chul Suh American Journal of Roentgenology. 2003;181: 583-590

Thank you for your time H. H. 2015