MRCP PACES Multiple Cranial Neuropathies Cavernous Sinus Syndrome
  • The cavernous sinuses are paired venous channels that lie on either side of the sphenoid bone
  • They extend from the superior orbital fissure to the petrous temporal bone
  • Contents of the cavernous sinuses:
    • Internal carotid artery
    • Sympathetic fibres
    • Oculomotor nerve
    • Trochlear nerve
    • Ophthalmic division of trigeminal (V1)
    • Maxillary division of trigeminal (V2)
    • Abducens nerve
  • Particularly localizing combination: abducens nerve palsy with Horner’s syndrome on the same side
  • Any combination of nerves may be affected
  • Symptoms and signs:
    • Painful ophthalmoplegia
    • Orbital congestion
    • Orbital chemosis
    • Periorbital oedema
    • Proptosis
    • Ipsilateral Horner’s syndrome
    • Ipsilateral loss of sensation in the distribution of ophthalmic and maxillary divisions of trigeminal
  • Causes:
    • Vascular:
      • Carotid artery aneurysm
      • Carotid-cavernous fistulas
        • Classic triad: pulsatile exophthalmos, chemosis, audible bruit over eye
      • Cavernous sinus thrombosis
    • Infections: usually from surrounding sinuses, most common causes: Staphylococcus, pneumococcus
    • Tumours
      • Direct extension: nasopharyngeal carcinoma, craniopharyngioma, pituitary adenoma
      • Metastatic disease
      • Primary tumour (meningioma, lymphoma)
    • Inflammatory (typically granulomatous processes)
      • Sarcoidosis
      • Wegner’s granulomatosis
      • Tolosa-Hunt syndrome (spontaneous resolution in one third, universal response to steroids)
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