Ocular Disease III - Cavernous sinus

Anterior boundary of cavernous sinus?

sup orbital fissure

Posterior boundary of cavernous sinus?

petrous apex of temporal bone

Medial boundary of cavernous sinus?

sphenoid sinus

Lateral boundary of cavernous sinus?

dural tissue

Vascular supply of cavernous sinus (venous and arterial)?

Venous = sup & inf ophthalmic v.
Arterial = smaller branches of int carotid

Drainage of cavernous sinus?

sup & inf petrosal sinuses

Connection of two cavernous sinuses?

intercavernous sinus

CNs in cavernous sinus?

CN III, IV, V1, VI

Oculosympathetic fibers in cavernous sinus?

Pupil dilator, sup lid elevation, inf lid depression

Just think "wide cavern" - all of these involve widening of the eye fissure or pupil

T/F - Pain is involved with cavernous sinus syndrome

True - orbital or hemicranial

T/F - Proptosis is possible with cavernous sinus syndrome.

True

T/F - Chemosis of the conj is possible w/ cavernous sinus syndrome.

True

Review causes of cavernous sinus syndrome

(Just a reminder)

What CN is most likely involved in pituitary adenomas within the cavernous sinus?

CN III - due to its position, close to pituitary

Laterality of pituitary adenomas - unilat, bilat, both?

Unilat or asymmetrical bilat

Pituitary adenomas are (fast/slow) growing, pituitary apoplexy are (fast/slow) growing

slow, fast

Pituitary apoplexies are caused by...

secondary to infarct or hemorrhage

Intercavernous aneurysms are due to an aneurysm of what BV?

internal carotid

T/F - Intercavernous aneurysms are slowly progressive.

True

T/F - Intercavernous aneurysms most likely involve CN III.

False - CN VI, due to location (But III, IV, and V1 can also be involved)

Note location of CN VI adjacent to carotid

T/F - Pts with intercavernous aneurysms causing CN III palsy will not have a dilated pupil.

True - pupil will be small and non-responsive to light and near

Describe how the pupil behaves in intercavernous aneurysms causing CN III palsy.

Sympathetic and parasymp fibers both involved, thus pupil is small and non-responsive to light or near

Rupture of intercavernous aneurysms result in...

carotid-cavernous fistula

Horner's with EOM palsy should make you think that the cause is...

in the cavernous sinus

Meningiomas are (slow/fast) growing and (malignant/benign)?

slow, benign

Most common benign intracranial tumor?

meningiomas

T/F - Meningiomas more commen in men.

False - women

You see engorged episcleral veins, increased IOP, chemosis, and lid edema; the pt has a Hx of a punch to the head. Dx?

Classic carotid-cavernous fistula; high pressure ICA blood travels up superior ophthalmic vein

What vessel does blood backflow thru in a classic carotid-cavernous fistula, causing chemosis, lid edema, engorged episcleral veins, etc?

superior ophthalmic vein

Dural-cavernous fistula happens by...

dural branches of ICA or external carotid into CS; tear in meningiohypophyseal artery most common

T/F - Dural-cavernous fistula typically middle aged elderly males.

False - females

Dural-cavernous fistula is (low/high) pressure, (low/high) flow.

low, low

What incr risk of Dural-cavernous fistula?

Arteriosclerosis, HTN, collagen vascular dz, pre-existing aneurysm/cong weakness

In your 60yo female pt, you see engorged episcleral veins and very high IOP. Since you suspect glaucoma, you check the angles and see blood in Schlemm's. You definitely need to R/O...

Dural-cavernous fistula

Dural-cavernous fistula has __ to __% spontaneous resolution within ___mos.

50, 60, 3

Mx of Dural-cavernous fistula?

neuro consult

Describe Tolosa-Hunt syndrome signs/Sx. What structures can be involved?

Painful & recurrent lasting days-weeks; severe periorbital or hemicranial pain.

Idiopathic, granulomatous inflammation of CS; Can involve CNs II-VII and oculosympathetics

Mx of Tolosa-Hunt syndrome?

Dx of exclusion - neuro consult, CT/MRI of orbit, steroids

Cause of Tolosa-Hunt syndrome?

Idiopathic