Cavernous Sinus Thrombosis: Presentation, Management, and Initial Diagnostic Uncertainty

Cavernous sinus thrombosis (CST) is a life-threatening diagnosis. Early CST may be difficult to detect, presenting without overt orbital findings or classic radiographic clues. The objective is to present the largest single-institution series characterizing presentation, imaging patterns, and surgical timing in patients with CST, and identify patterns of diagnostic uncertainty in early CST.

Retrospective cohort of 33 patients meeting radiologic criteria for CST. Initial diagnostic uncertainty (IDU) was defined as prior discharge or transfer with a diagnosis other than CST.

11 patients (33%) experienced IDU, commonly discharged from the Emergency Department with migraine, muscle strain, or uncomplicated sinusitis. Neck pain was associated with delay (55% vs. 9.1%; p = 0.008), and delayed patients were younger (40 vs. 64 years; p = 0.005). Headache (63%), exophthalmos (53%), and cranial neuropathies (CNs) were common presenting signs. On imaging, sphenoid opacification (79%), bony erosion (31%), superior ophthalmic vein thrombosis (50%), and bilateral CST (34%) were common. Median time from symptom onset to presentation was 4.5 days with 90% receiving sinus surgery. 94% were anticoagulated with major hemorrhage in 12%. At imaging follow-up (median 17 days), 70% had partial or complete CST resolution. About 54% of eyes had any visual impairment and 9% had total or near total visual loss.

Sphenoid sinusitis with headache, CN, orbital findings, or neck pain should prompt suspicion and further evaluation for CST. Awareness of subtle presentations, especially in younger patients, and aggressive early intervention can prevent irreversible injury. Sinus surgery plays an important role for source control and cultures.