Most Cavernous Sinus Thrombosis Cases Have a Septic Origin

In the largest case series to date in the ophthalmic literature focusing on cavernous sinus thrombosis (CST), presenters at the American Society of Ophthalmic Plastic and Reconstructive Surgery Fall Scientific Symposium confirmed that most cases are septic in origin.

CST can be triggered by septic (infectious) or aseptic (noninfectious) causes such as trauma, malignancy, or hypercoagulability. Past research has focused on septic CST because it comprises most CST cases, roughly 83%. While mortality from septic CST has been greatly reduced by the use of antibiotics, morbidity remains high, and 14% to 17% of patients with septic CST experience vision loss. There are no reported studies of morbidity and mortality associated with aseptic CST. 

Proposed etiologies of CST include central retinal artery occlusion, anterior ischemic optic neuropathy, and toxic neuritis of the optic nerve caused by the adjacent purulent inflammation. 

For their study, the Vanderbilt University-based investigators conducted a retrospective chart review of 18 identified patients with CST confirmed by magnetic resonance imaging or CT imaging who presented to a tertiary care center from 2007 to 2020. Among the 17 patients included in the study (1 patient died in hospital and was removed from length-of-stay analysis), 11 (65%) had an infectious CST etiology. This group included patients with sinusitis (7 patients), bacteremia (2 patients), facial infection (1 patient), and mastoiditis (1 patient). Of the 2 cases with bacteremia, 1 was secondary to endocarditis and 1 was secondary to spinal epidural abscess. The remaining 6 (35%) patients in the study had aseptic CST. Specifically, 2 had CST associated with carotid-cavernous fistulae, 2 had CST due to known or suspected malignancy, and 2 had idiopathic CST. 

Mean presenting visual acuity in symptomatic eyes was approximately 20/40. The median time from symptoms to diagnosis of CST was 5.0 days (mean, 11.5 days). Median time from admission to diagnosis of CST was 0 days (mean, 1.2 days). Median time from admission to intervention, whether surgery or anticoagulation, was 1.5 days (mean, 1.5 days). A total of 8 patients underwent surgical intervention (endoscopic sinus surgery in 6 patients, mastoidectomy in 1 patient, and orbitotomy in 1 patient). 

While longer time to intervention was correlated with a longer length of stay, this finding was not statistically significant (P =.06). Two patients (12%) died. Among patients with worse visual acuity at presentation, there was no association with worse visual acuity at final follow-up. Additionally, length of hospital stay was not significantly correlated with time from initial symptoms to CST diagnosis nor time from admission to CST diagnosis. 

The researchers concluded that both diagnosis of CST and subsequent intervention are accomplished promptly once patients are transferred to a tertiary care center. In line with current literature, data from this study supports that the majority of CST cases are of a septic etiology. Furthermore, while anticoagulation therapy was the intervention of choice for both septic and aseptic CST, surgical intervention was more common in septic cases than in aseptic ones, which rarely require surgery. Length of stay was longer in septic CST cases but survival was not associated strongly with any of the variables assessed. 

While the investigators noted that their study represents “the largest case series of patients with CST in the ophthalmic literature to date,” they emphasized that multi-institutional studies or studies with a larger sample size would offer greater insights into vision and survival predictors in CST. 

Reference 

Timtim E, Law JJ, Chen Q, Barahimi B, Mawn LA, Sobel RK. Vision and survival outcomes in infectious and non-infectious cavernous sinus thrombosis. Poster presented at: American Society of Ophthalmic Plastic and Reconstructive Surgery 52nd Annual Fall Scientific Symposium; November 11-12, 2021; New Orleans.