Eur Arch Otorhinolaryngol (1991) 248 : 422-424
European Archives of
Oto-RhinoLaryngology © Springer-Verlag 1991
Case reports
Cavernous sinus thrombosis following odontogenic and cervicofacial infection M. Wen-Der Yun 1, C. E Hwang 1, and C. C. Lui 2 Departments of 10tolaryngology and 2Radiology, Chang-Gung Memorial Hospital, Kaohsiung, Taiwan, R.O.C. Received October 31, 1990 / Accepted January 7, 1991
S u m m a r y . C a v e r n o u s sinus t h r o m b o s i s ( C S T ) is r a r e l y seen clinically as a c o m p l i c a t i o n o f infectious p r o c e s s e s since the discovery o f penicillin. A t the p r e s e n t t i m e , dental abscess is an u n c o m m o n cause o f CST. W e n o w rep o r t o u r e x p e r i e n c e s with a 6 0 - y e a r - o l d d i a b e t i c m a l e , w h o d e v e l o p e d C S T 38 d a y s after e x t r a c t i o n o f an infected upper third molar tooth. The importance of eradicating r e g i o n a l cervicofacial foci o f i n f e c t i o n is stressed.
Key words: C a v e r n o u s sinus t h r o m b o s i s - I n f e c t i o n D e n t a l diseases
Introduction S e p t i c t h r o m b o s i s o f t h e c a v e r n o u s sinus is an u n u s u a l b u t s e v e r e a n d o f t e n l e t h a l c o m p l i c a t i o n o f focal infections in t h e h e a d o r n e c k . It m o s t c o m m o n l y follows infections of t h e m i d - f a c e . O t h e r a n t i c e d e n t sites o f infection i n c l u d e p a r a n a s a l (usually s p h e n o i d ) sinusitis, otitis m e d i a a n d d e n t a l abscesses [2]. I n the p r e - a n t i b i o t i c era, c a v e r n o u s sinus t h r o m b o s i s ( C S T ) was a f r e q u e n t c o m p l i c a t i o n o f d e n t a l infections. Surgical m a n a g e m e n t was t h e o n l y t r e a t m e n t of choice, b u t this t r e a t m e n t was also c o m m o n l y a s s o c i a t e d with significant m o r b i d i t y a n d m o r t a l i t y . W i t h the a d v e n t o f penicillin a n d o t h e r antibiotics, successful t r e a t m e n t o f C S T has b e c o m e m o r e likely. H o w e v e r , septic t h r o m b o s i s o f t h e c a v e r n o u s sinus d u e to o d o n t o g e n i c infections is still a r a r i t y at the p r e s e n t t i m e . W e n o w r e p o r t o u r e x p e r i e n c e s with o n e such p a t i e n t .
Case report A 60-year-old Chinese male with a 15-year history of diabetes mellitus presented to his dentist with a 1-week history of toothache and subsequent painful right cheek. Blood sugar had been controlled satisfactorily by diet and oral hypoglycemic medication alone. Offprint requests to: M.Wen-Der Yun, 316 Bor-Ay Rd. Sec. 1, Kaohsiung, Taiwan, R.O.C.
Examination showed a swollen and tender right cheek, with frank pus from the upper right third molar tooth. This tooth was extracted, followed by an 8-day course of antibiotics (ticarcillin and gentamicin) based on a culture growth of Pseudornonas aeruginosa. During the immediate period after the extraction, the patient did well, with both clinical and laboratory improvement of illness. Regular follow-ups were also kept at 2-day intervals. On the 15th day after the dental extraction, the patient began to suffer from chills and fever in addition to more extensive cheek pain. He was then referred to a regional hospital for further workup. On admission, the patient looked moderately ill. His axillary temperature was 38.7°C, pulse rate 108/min and respiratory rate 28/min. The leukocyte count was 13,000/mm 3, with 86% neutrophils. Fasting sugar was 277mg/dl, blood urea nitrogen (BUN) 22mg/dl, creatinine 1.1mg/dl. An impression of maxillary osteomyelitis with deep facial infection was made after radiological examinations. Twenty-four hours after admission, incision and drainage were done on the right buccal area and preauricular region, resulting in the evacuation of 120 ml pus. Admission blood cultures and cultures from the pus all revealed P. aeruginosa and Enterococcus. Organism sensitivities resulted in the usage of 2 g vancomycin/day for better coverage of Enterococcus in addition to 12 g/day ticarcillin plus 240 mg/day gentamicin. Fever subsided and the leukocyte count returned to 7,100/ram 3 within 3-5 days, although blood sugar still fluctuated between 120 and 290 mg/dl. One week after admission, the patient began to feel somewhat weak, but with the only abnormal findings of a blood sugar being 280 mg/dl. His blood pressure became unstable and urine output decreased. White blood cell count (WBC) was 3,800/mm 3, platelet count 17,000/ mm 3, BUN 90mg/dl, creatinine 12mg/dl. During the following week, upper gastrointestinal bleeding ensued with altered levels of consciousness. A clinical diagnosis was made of septic shock with secondary acute renal shutdown and disseminated intravascular coagulation. The patient was now admitted to the intensive care unit (ICU), where peritoneal dialysis was started. Culture results and sensitivity tests still justified the usage of the same antibiotics used previously. Heparin was also started with the diagnosis of disseminated intravascular coagulation in order to maintain the partial thromboplastic time at twice control. Nineteen days after admission, vital signs and renal function recovered to normal ranges, allowing discharge from the ICU. Although control of sugar remained satisfactory, pus still continued to drain from the right preauricular area. Further debridement to eradicate residual cervicofacial infection was advised but was refused by the patient. Two days later, right periorbital and lid edema occurred on waking and limitation of right lateral gaze was found. This progressed rapidly to complete fixation of the eye
M. W. Yun et al. : Cavernous sinus thrombosis
423
Fig. 3. Plain CT demonstrating involvement of the right parotid space (arrowhead), the infratemporal fossa, and soft tissue beside the pterygoid plate (arrow)
Fig. 1. Ptosis and mild proptosis of the right eye
Since antibiotics were still considered to be appropriate and blood sugar levels continued to improve, inadequate control of infection was attributed to failed drainage of the persistent cervicofacial abscess. Revised incision and drainage were done, following which heparin was added to the antibiotic regimen. This resulted in reversal of eye findings within 48 h of surgery and remission of all clinical and laboratory evidence of infection 10 days after surgery. Persistent paralysis of the right extraocular muscles showed minimal improvement during regular follow-ups 5 months after treatment.
Discussion
Fig. 2. Contrast-enhanced CT film showing fullness of the right cavernous sinus with lateral bulging of the dura, and a curvilinear radiolucency (arrow)
within 24 h. Transfer to our medical center was then effected for further care. On arrival, the patient was found to be acutely ill. Axillary temperature was 38.5°C, blood t?ressure 136/88mm Hg. Leukocyte count was WBC 11,900/mm ~ with 67% neutrophils, plasma sugar 114 mg/dl and BUN 26 mg/dl. Right eye signs included ptosis, proptosis, and chemosis. The pupil was mildly dilated and the light reflex was sluggish. The right disc margin was blurred but vision was intact. There was complete paralysis of the extraocular muscles (Fig. 1). Retro-orbital pain was demonstrable and was found in the sensory distribution of the first branch of the trigeminal nerve. Computed tomography with contrast enhancement revealed involvement of the right cavernous sinus (Fig. 2) and soft tissue swelling extending from the right masseter space to the infratemporal and superior parapharyngeal spaces (Fig. 3). Erosion of the right mandibular condyle was also noted. These films together with clinical findings were sufficient for a diagnosis of septic CST.
In a 1945 review of intracranial infection following dental extraction, H a y m a k e r [5] f o u n d that 11 of 28 fatal cases were due to involvement of the cavernous sinuses. This complication is u n c o m m o n l y seen since the introduction of antibiotic t r e a t m e n t to clinical medicine but still comprises a b o u t 10% of septic CST [7]. Spread of infection from infected teeth proceeds mainly by v e n o u s pathways. T h e occurrence of sepsis and disseminated intravascular coagulation in our case has possibly fulfilled the three factors which are t h o u g h t to be necessary for a t h r o m b u s to f o r m in the cavernous sinus, including d a m a g e to the intima of a vessel wall, hypercoagulability of the blood, and vascular stasis [9]. W e believe that infected loci f r o m o u r patient's dental abscess involved the r e t r o m a n d i b u l a r vein or its connecting veins and then spread to the unvalved cavernous sinus via the pterygoid venous plexus. This latter plexus constitutes the "posterior r o u t e " for spread of infection. T h e "anterior r o u t e " consists mainly of v e n o u s collaterals f r o m the ophthalmic vein and is the usual p a t h w a y for the classic clinical picture of fulminating CST [7]. T h e two cavernous sinuses are c o n n e c t e d by the intercavernous sinus and s u r r o u n d the sella turcica in the sphenoid b o n e (Fig. 4). T h e o c u l o m o t o r and trochlear nerves and the first division of the trigeminal nerve course along the lateral wall of the cavernous sinus. T h e abducens nerve passes t h r o u g h the center of the sinus [4], so that a lateral gaze palsy m a y be an isolated early sign of CST and can precede a full-blown ophthalmoplegia. Other
424
Fig. 4. Frontal section through hypophysis (H) and sphenoid sinus (S) illustrating relation of cavernous sinus (CS) to multiple cranial nerves (III, IV, V1, V2, VI), and internal carotid artery (ICA)
cranial nerve signs include a diminished corneal reflex, pain or paresthesia along the distribution of the first or second division of the trigeminal nerve, ptosis and a dilated and fixed pupil. Proptosis, chemosis and dilation of ipsilateral ocular vessels comprise the signs caused by blockage of the ophthalmic vein [1]. Chills, fever and headache are also c o m m o n systemic findings. Magnetic resonance imaging is now the diagnostic examination of first choice in cases of CST and can differentiate stages of thrombus evolution [6]. However, computed t o m o g r a p h y with intravenous contrast is still helpful, especially since these studies can demonstrate occlusion of the sinus or a dilated superior ophthalmic vein. The diagnostic yield of computed t o m o g r a p h y can be increased further by such modifications as examinations using higher doses of contrast material followed by rapid sequential views, thin sections, multiplanar reconstructions and direct coronal scanning [3, 8]. Therapy in our patient included control of plasma sugar levels, appropriate antibiotic coverage, management of shock, administration of heparin to treat the early stage of disseminated intravascular coagulation and CST and surgical evacuation of infection. However, the use of anticoagulants in CST has been controversial. In a study by Steven et al. [10], anticoagulant therapy
M. W. Yun et al.: Cavernous sinus thrombosis was thought to be indicated within 1 week of the onset of CST to reduce morbidity, although no conclusive evidence exists to show that it can reduce mortality. Complications of CST include ophthalmoparesis, blindness, focal seizures, vascular steal syndrome, hemiparesis and hypopituitarism. Although sufficient heparin was given at an early stage of our patient's disease (the 2nd day of ocular symptoms), right ophthalmoplegia has persisted. We conclude that usage of heparin still remains controversial.
Acknowledgements. Y. Y. Wang and C. Y. Su are thanked for their assistance in the completion of this paper.
References 1. Chisolm J, Watkins SS (1920) Twelve cases of thrombosis of the cavernous sinus. Arch Surg 1:483-512 2. DiNubile MJ (1988) Septic thrombosis of the cavernous sinuses. Arch Neurol 45 : 567-572 3. Goldberg AL, Rosenbaum AE, Wang H, Kim WS, Van L, Hanley DF (1986) Computed tomography of dural sinus thrombosis. J Comput Assist Tomogr 10 : 16-20 4. Harris FS, Rhoton AL Jr (1976) Anatomy of the cavernous sinus, a microsurgical study. J Neurosurg 45 : 169-180 5. Haymaker W (1945) Fatal infections of the central nervous system and meninges after tooth extraction, with analysis of 28 cases. Am J Orthod Dentofacial Orthop 31 : 117-188 6. Macchi PJ, Grossman RI, Gomori JM, Goldberg HI, Zimmerman RA, Bilaniuk LT (1986) High-field MR imaging of cerebral venous thrombosis. J Comput Assist Tomogr 10 : 10-15 7. Palmersheim LA, Hamilton MK (1982) Fatal cavernous sinus thrombosis following third molar removal. J Oral Maxillofac Surg 40: 371-376 8. Rao KC, Knipp HC, Wagner EJ (1981) Computed tomographic findings in cerebral sinus and venous thrombosis. Radiology 140 : 391-398 9. Scarpellino LA, Stookey PF, Hall FJ (1936) The pathogenesis of cavernous sinus thrombosis. J Missouri State Med Assoc 33 : 251-257 10. Steven RL, Roy ET, Sid G (1988) The role of anticoagulation in cavernous sinus thrombosis. Neurology 38:517-522
European Archives of
Oto-RhinoLaryngology © Springer-Verlag 1991
Case reports
Cavernous sinus thrombosis following odontogenic and cervicofacial infection M. Wen-Der Yun 1, C. E Hwang 1, and C. C. Lui 2 Departments of 10tolaryngology and 2Radiology, Chang-Gung Memorial Hospital, Kaohsiung, Taiwan, R.O.C. Received October 31, 1990 / Accepted January 7, 1991
S u m m a r y . C a v e r n o u s sinus t h r o m b o s i s ( C S T ) is r a r e l y seen clinically as a c o m p l i c a t i o n o f infectious p r o c e s s e s since the discovery o f penicillin. A t the p r e s e n t t i m e , dental abscess is an u n c o m m o n cause o f CST. W e n o w rep o r t o u r e x p e r i e n c e s with a 6 0 - y e a r - o l d d i a b e t i c m a l e , w h o d e v e l o p e d C S T 38 d a y s after e x t r a c t i o n o f an infected upper third molar tooth. The importance of eradicating r e g i o n a l cervicofacial foci o f i n f e c t i o n is stressed.
Key words: C a v e r n o u s sinus t h r o m b o s i s - I n f e c t i o n D e n t a l diseases
Introduction S e p t i c t h r o m b o s i s o f t h e c a v e r n o u s sinus is an u n u s u a l b u t s e v e r e a n d o f t e n l e t h a l c o m p l i c a t i o n o f focal infections in t h e h e a d o r n e c k . It m o s t c o m m o n l y follows infections of t h e m i d - f a c e . O t h e r a n t i c e d e n t sites o f infection i n c l u d e p a r a n a s a l (usually s p h e n o i d ) sinusitis, otitis m e d i a a n d d e n t a l abscesses [2]. I n the p r e - a n t i b i o t i c era, c a v e r n o u s sinus t h r o m b o s i s ( C S T ) was a f r e q u e n t c o m p l i c a t i o n o f d e n t a l infections. Surgical m a n a g e m e n t was t h e o n l y t r e a t m e n t of choice, b u t this t r e a t m e n t was also c o m m o n l y a s s o c i a t e d with significant m o r b i d i t y a n d m o r t a l i t y . W i t h the a d v e n t o f penicillin a n d o t h e r antibiotics, successful t r e a t m e n t o f C S T has b e c o m e m o r e likely. H o w e v e r , septic t h r o m b o s i s o f t h e c a v e r n o u s sinus d u e to o d o n t o g e n i c infections is still a r a r i t y at the p r e s e n t t i m e . W e n o w r e p o r t o u r e x p e r i e n c e s with o n e such p a t i e n t .
Case report A 60-year-old Chinese male with a 15-year history of diabetes mellitus presented to his dentist with a 1-week history of toothache and subsequent painful right cheek. Blood sugar had been controlled satisfactorily by diet and oral hypoglycemic medication alone. Offprint requests to: M.Wen-Der Yun, 316 Bor-Ay Rd. Sec. 1, Kaohsiung, Taiwan, R.O.C.
Examination showed a swollen and tender right cheek, with frank pus from the upper right third molar tooth. This tooth was extracted, followed by an 8-day course of antibiotics (ticarcillin and gentamicin) based on a culture growth of Pseudornonas aeruginosa. During the immediate period after the extraction, the patient did well, with both clinical and laboratory improvement of illness. Regular follow-ups were also kept at 2-day intervals. On the 15th day after the dental extraction, the patient began to suffer from chills and fever in addition to more extensive cheek pain. He was then referred to a regional hospital for further workup. On admission, the patient looked moderately ill. His axillary temperature was 38.7°C, pulse rate 108/min and respiratory rate 28/min. The leukocyte count was 13,000/mm 3, with 86% neutrophils. Fasting sugar was 277mg/dl, blood urea nitrogen (BUN) 22mg/dl, creatinine 1.1mg/dl. An impression of maxillary osteomyelitis with deep facial infection was made after radiological examinations. Twenty-four hours after admission, incision and drainage were done on the right buccal area and preauricular region, resulting in the evacuation of 120 ml pus. Admission blood cultures and cultures from the pus all revealed P. aeruginosa and Enterococcus. Organism sensitivities resulted in the usage of 2 g vancomycin/day for better coverage of Enterococcus in addition to 12 g/day ticarcillin plus 240 mg/day gentamicin. Fever subsided and the leukocyte count returned to 7,100/ram 3 within 3-5 days, although blood sugar still fluctuated between 120 and 290 mg/dl. One week after admission, the patient began to feel somewhat weak, but with the only abnormal findings of a blood sugar being 280 mg/dl. His blood pressure became unstable and urine output decreased. White blood cell count (WBC) was 3,800/mm 3, platelet count 17,000/ mm 3, BUN 90mg/dl, creatinine 12mg/dl. During the following week, upper gastrointestinal bleeding ensued with altered levels of consciousness. A clinical diagnosis was made of septic shock with secondary acute renal shutdown and disseminated intravascular coagulation. The patient was now admitted to the intensive care unit (ICU), where peritoneal dialysis was started. Culture results and sensitivity tests still justified the usage of the same antibiotics used previously. Heparin was also started with the diagnosis of disseminated intravascular coagulation in order to maintain the partial thromboplastic time at twice control. Nineteen days after admission, vital signs and renal function recovered to normal ranges, allowing discharge from the ICU. Although control of sugar remained satisfactory, pus still continued to drain from the right preauricular area. Further debridement to eradicate residual cervicofacial infection was advised but was refused by the patient. Two days later, right periorbital and lid edema occurred on waking and limitation of right lateral gaze was found. This progressed rapidly to complete fixation of the eye
M. W. Yun et al. : Cavernous sinus thrombosis
423
Fig. 3. Plain CT demonstrating involvement of the right parotid space (arrowhead), the infratemporal fossa, and soft tissue beside the pterygoid plate (arrow)
Fig. 1. Ptosis and mild proptosis of the right eye
Since antibiotics were still considered to be appropriate and blood sugar levels continued to improve, inadequate control of infection was attributed to failed drainage of the persistent cervicofacial abscess. Revised incision and drainage were done, following which heparin was added to the antibiotic regimen. This resulted in reversal of eye findings within 48 h of surgery and remission of all clinical and laboratory evidence of infection 10 days after surgery. Persistent paralysis of the right extraocular muscles showed minimal improvement during regular follow-ups 5 months after treatment.
Discussion
Fig. 2. Contrast-enhanced CT film showing fullness of the right cavernous sinus with lateral bulging of the dura, and a curvilinear radiolucency (arrow)
within 24 h. Transfer to our medical center was then effected for further care. On arrival, the patient was found to be acutely ill. Axillary temperature was 38.5°C, blood t?ressure 136/88mm Hg. Leukocyte count was WBC 11,900/mm ~ with 67% neutrophils, plasma sugar 114 mg/dl and BUN 26 mg/dl. Right eye signs included ptosis, proptosis, and chemosis. The pupil was mildly dilated and the light reflex was sluggish. The right disc margin was blurred but vision was intact. There was complete paralysis of the extraocular muscles (Fig. 1). Retro-orbital pain was demonstrable and was found in the sensory distribution of the first branch of the trigeminal nerve. Computed tomography with contrast enhancement revealed involvement of the right cavernous sinus (Fig. 2) and soft tissue swelling extending from the right masseter space to the infratemporal and superior parapharyngeal spaces (Fig. 3). Erosion of the right mandibular condyle was also noted. These films together with clinical findings were sufficient for a diagnosis of septic CST.
In a 1945 review of intracranial infection following dental extraction, H a y m a k e r [5] f o u n d that 11 of 28 fatal cases were due to involvement of the cavernous sinuses. This complication is u n c o m m o n l y seen since the introduction of antibiotic t r e a t m e n t to clinical medicine but still comprises a b o u t 10% of septic CST [7]. Spread of infection from infected teeth proceeds mainly by v e n o u s pathways. T h e occurrence of sepsis and disseminated intravascular coagulation in our case has possibly fulfilled the three factors which are t h o u g h t to be necessary for a t h r o m b u s to f o r m in the cavernous sinus, including d a m a g e to the intima of a vessel wall, hypercoagulability of the blood, and vascular stasis [9]. W e believe that infected loci f r o m o u r patient's dental abscess involved the r e t r o m a n d i b u l a r vein or its connecting veins and then spread to the unvalved cavernous sinus via the pterygoid venous plexus. This latter plexus constitutes the "posterior r o u t e " for spread of infection. T h e "anterior r o u t e " consists mainly of v e n o u s collaterals f r o m the ophthalmic vein and is the usual p a t h w a y for the classic clinical picture of fulminating CST [7]. T h e two cavernous sinuses are c o n n e c t e d by the intercavernous sinus and s u r r o u n d the sella turcica in the sphenoid b o n e (Fig. 4). T h e o c u l o m o t o r and trochlear nerves and the first division of the trigeminal nerve course along the lateral wall of the cavernous sinus. T h e abducens nerve passes t h r o u g h the center of the sinus [4], so that a lateral gaze palsy m a y be an isolated early sign of CST and can precede a full-blown ophthalmoplegia. Other
424
Fig. 4. Frontal section through hypophysis (H) and sphenoid sinus (S) illustrating relation of cavernous sinus (CS) to multiple cranial nerves (III, IV, V1, V2, VI), and internal carotid artery (ICA)
cranial nerve signs include a diminished corneal reflex, pain or paresthesia along the distribution of the first or second division of the trigeminal nerve, ptosis and a dilated and fixed pupil. Proptosis, chemosis and dilation of ipsilateral ocular vessels comprise the signs caused by blockage of the ophthalmic vein [1]. Chills, fever and headache are also c o m m o n systemic findings. Magnetic resonance imaging is now the diagnostic examination of first choice in cases of CST and can differentiate stages of thrombus evolution [6]. However, computed t o m o g r a p h y with intravenous contrast is still helpful, especially since these studies can demonstrate occlusion of the sinus or a dilated superior ophthalmic vein. The diagnostic yield of computed t o m o g r a p h y can be increased further by such modifications as examinations using higher doses of contrast material followed by rapid sequential views, thin sections, multiplanar reconstructions and direct coronal scanning [3, 8]. Therapy in our patient included control of plasma sugar levels, appropriate antibiotic coverage, management of shock, administration of heparin to treat the early stage of disseminated intravascular coagulation and CST and surgical evacuation of infection. However, the use of anticoagulants in CST has been controversial. In a study by Steven et al. [10], anticoagulant therapy
M. W. Yun et al.: Cavernous sinus thrombosis was thought to be indicated within 1 week of the onset of CST to reduce morbidity, although no conclusive evidence exists to show that it can reduce mortality. Complications of CST include ophthalmoparesis, blindness, focal seizures, vascular steal syndrome, hemiparesis and hypopituitarism. Although sufficient heparin was given at an early stage of our patient's disease (the 2nd day of ocular symptoms), right ophthalmoplegia has persisted. We conclude that usage of heparin still remains controversial.
Acknowledgements. Y. Y. Wang and C. Y. Su are thanked for their assistance in the completion of this paper.
References 1. Chisolm J, Watkins SS (1920) Twelve cases of thrombosis of the cavernous sinus. Arch Surg 1:483-512 2. DiNubile MJ (1988) Septic thrombosis of the cavernous sinuses. Arch Neurol 45 : 567-572 3. Goldberg AL, Rosenbaum AE, Wang H, Kim WS, Van L, Hanley DF (1986) Computed tomography of dural sinus thrombosis. J Comput Assist Tomogr 10 : 16-20 4. Harris FS, Rhoton AL Jr (1976) Anatomy of the cavernous sinus, a microsurgical study. J Neurosurg 45 : 169-180 5. Haymaker W (1945) Fatal infections of the central nervous system and meninges after tooth extraction, with analysis of 28 cases. Am J Orthod Dentofacial Orthop 31 : 117-188 6. Macchi PJ, Grossman RI, Gomori JM, Goldberg HI, Zimmerman RA, Bilaniuk LT (1986) High-field MR imaging of cerebral venous thrombosis. J Comput Assist Tomogr 10 : 10-15 7. Palmersheim LA, Hamilton MK (1982) Fatal cavernous sinus thrombosis following third molar removal. J Oral Maxillofac Surg 40: 371-376 8. Rao KC, Knipp HC, Wagner EJ (1981) Computed tomographic findings in cerebral sinus and venous thrombosis. Radiology 140 : 391-398 9. Scarpellino LA, Stookey PF, Hall FJ (1936) The pathogenesis of cavernous sinus thrombosis. J Missouri State Med Assoc 33 : 251-257 10. Steven RL, Roy ET, Sid G (1988) The role of anticoagulation in cavernous sinus thrombosis. Neurology 38:517-522
