1. Cavernous Sinus Syndrome
Dr Hani Hasan
Specialty Doctor in Ophthalmology

2. Demographics
Gender: Female
Age: 57 years

3. Presenting symptoms
Double vision 3 months
Headache 2 months

4. 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.

5. 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

6. 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.

7. 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.

8. 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.

9. 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.

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

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

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

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

14. 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.

15. Diagnosis
Left Cavernous Sinus Syndrome.

16. Discussion

17. Cavernous sinus syndrome
Causes:
Neoplasia
Infections
Inflammation
Vascular lesions

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

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

20. 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.

21. 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

22. E.g. Cavernous sinus tumors

23. 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.

24. 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:

25. Thank you for your time
H. H. 2015