Early Cavernous Sinus Thrombosis-Gd MRI

The cavernous sinuses receive venous blood from the facial veins (via the superior and inferior ophthalmic veins) as well as the sphenoid and middle cerebral veins. They, in turn, empty into the inferior petrosal sinuses, then into the internal jugular veins and the sigmoid sinuses via the superior petrosal sinuses. This complex web of veins contains no valves; blood can flow in any direction depending on the prevailing pressure gradients. This is diabetic female with clinical history of multiple cranial nerve palsies. Case submitted by Dr MGK Murthy.

Teaching points

• Multiple cranial nerve palsies in diabetic lady should always suggest infection base of the skull and venous thrombosis unless other wise proved
• Superior opthalmic vein is sensitive indicator of things hapening in cavernous sinus 
• Base of the  skull in this case shows diffuse enhancing oedema -producing literally sheet of gadolinium possibly encasing all the foramina at base including foramen ovale
•  Widened cavernous sinus with some asymetry is suggestive of stasis and thrombus along with asymmetry of flow void of ICA within
• No proptosis is no guarantee against venous thrombosis 
• Sphenoid sinus is is notorious for producing base of the skull and meningeal inflammation
• All muslces and soft tissues including temporalis are inflammed