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Pictorial Essay
Cavernous Sinus Syndrome: Clinical Features and
Differential Diagnosis with MR Imaging
Jeong Hyun Lee1, Ho Kyu Lee1, Ji Kang Park2, Choong Gon Choi1, Dae Chul Suh1

T
he cavernous sinus is a small but include bacterial or fungal infections, non- that help to make the differential diagnosis
complex structure consisting of infectious inflammation, vascular lesions, of these diseases.
a venous plexus, the carotid ar- and neoplasms. In this report, we briefly re-
tery, cranial nerves, and sympathetic fibers. view the normal anatomy of the cavernous
Broad categories of diseases involving the sinus, illustrate a variety of the primary Normal Anatomy of the Cavernous Sinus
cavernous sinus can cause the so-called pathologic conditions that can affect this The cavernous sinuses consist of extradu-
cavernous sinus syndrome; these diseases structure, and discuss the imaging features ral venous plexuses surrounded by a dural

A B
Fig. 1.—Anatomic diagrams of cavernous sinus.
A and B, Drawings of coronal (A) and lateral (B) views show structure of cavernous sinus. 1 = carotid artery, 2 = oculomotor nerve, 3 = trochlear nerve, 4 = ophthalmic
nerve, 5 = maxillary nerve, 6 = abducens nerve, 7 = pituitary gland, 8 = sympathetic nerve, 9 = mandibular nerve.

Received July 29, 2002; accepted after revision January 2, 2003.

Presented at the annual meeting of the Radiological Society of North America, Chicago, November 2001.
1
Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-dong, Songpa-gu, Seoul, Korea. Address correspondence to H. K. Lee.
2
Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, 1290-3 Jeonha-dong, Dong-gu, Ulsan, 682-060, Korea.
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 Lee et al.

Fig. 2.—Cavernous sinus thrombophlebitis caused by paranasal sinusitis in 62-year-old

woman with right ocular pain and diplopia due to oculomotor, trochlear, and abducens
nerve palsy.
A, Coronal T2-weighted image shows asymmetric bulging of right cavernous sinus
(arrows). Note hyperintense thick mucosa of right sphenoidal sinus due to sinusitis.
B and C, Contrast-enhanced coronal (B) and axial (C) T1-weighted images show diffuse en-
hancement of right orbital contents due to orbital cellulitis and ophthalmitis. Note nonen-
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hancing acute thrombus (arrows, C) in right cavernous sinus.

B C

A B

Fig. 3.—Cavernous sinus thrombophlebitis and skull base osteomyelitis in 58-year-old woman with left ocular pain and diplopia due to left abducens nerve palsy after tooth extraction.
A and B, Contrast-enhanced coronal (A) and axial (B) T1-weighted images show enlarged cavernous sinuses with lateral convexity and luminal narrowing of right carotid
artery (arrow, A). Note multiple filling defects due to thrombosis in cavernous sinuses (solid arrows, B) and in left inferior ophthalmic vein (open arrows, B), which is one
tributary of cavernous sinus. Also note heterogeneous enhancement of clival fat marrow (C, A).

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 MR Imaging of Cavernous Sinus Syndrome
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A B

Fig. 4.—Actinomycosis in 27-year-old man with severe frontal headache and de-
creased visual acuity.
A and B, Axial T1-weighted (A) and T2-weighted (B) images show ill-defined isoin-
tense lesion (arrows, A) in left anterior cavernous sinus and orbital apex.
C, Coronal contrast-enhanced T1-weighted image shows intense and homoge-
neous enhancement of lesion. Note encasement of left carotid artery with luminal
narrowing (arrow).

C
fold. The intracavernous internal carotid ar- medial to the oculomotor and trochlear Cavernous Sinus Syndrome
tery with its periarterial sympathetic plexus nerves and the ophthalmic and maxillary di- Cavernous sinus syndrome is character-
runs between the venules of the parasellar visions of the trigeminal nerve, which run ized by multiple cranial neuropathies. The
venous plexus (Fig. 1). The abducens nerve superior to inferior within the lateral dural clinical presentation includes impairment of
runs lateral to the internal carotid artery, but border of the cavernous sinus [1]. ocular motor nerves, Horner’s syndrome,

A B

Fig. 5.—Rhinocerebral mucormycosis in 61-year-old diabetic man with diplopia due to right oculomotor and trochlear nerve palsy.
A, On contrast-enhanced CT scan, right cavernous sinus does not enhance by contrast agent (arrows). CT scan also reveals acute infarction of anterior temporal lobe (T).
B, Contrast-enhanced coronal T1-weighted image shows nonenhancing isointense lesion filling adjacent right sphenoidal sinus due to fungal sinusitis and luminal narrow-
ing of right carotid artery.

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 Lee et al.
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A B C

Fig. 6.—Aspergillosis in 55-year-old man with diplopia due to oculomotor nerve palsy. He had been treated for biliary sepsis.
A and B, Axial T2-weighted image (A) shows hypointense lesion (straight arrows, A) in left cavernous sinus, which is isointense on T1-weighted image (B). Normal signal
void of carotid artery is replaced by acute thrombus (curved arrows).
C, On coronal contrast-enhanced T1-weighted image, thrombus extends into distal internal carotid artery (curved arrow). Within sphenoidal sinus, isointense fungal mass
(straight arrows) surrounded by enhanced mucosa is identified.

and sensory loss of the first or second divi- The diagnosis is based primarily on clinical from the ear or sinuses or hematogenous
sions of the trigeminal nerve in various com- data. CT and MR imaging can provide diag- spread from a distant source. Radiographi-
binations. The pupil may be involved or nostic information with direct signs, includ- cally, actinomycosis may appear as an irreg-
spared or may appear spared with concomi- ing changes in signal intensity and in the size ularly marginated, rim-enhancing abscess; as
tant oculosympathetic and parasympathetic and contour of the cavernous sinus, and indi- meningoencephalitis; or as a mass lesion [3]
involvement. Various degrees of pain may be rect signs, including dilatation of the tribu- (Fig. 4).
involved [1]. tary veins, exophthalmos, and increased
dural enhancement along the lateral border Rhinocerebral Mucormycosis
of the cavernous sinus [2] (Figs. 2 and 3). Fungi of the order Mucorales have mini-
Infectious Diseases
mal intrinsic pathogenicity but can cause ful-
Cavernous Sinus Thrombophlebitis Actinomycosis minant infection in immunocompromised
Thrombophlebitis of the cavernous sinus Actinomycosis is a rare disease. Most pa- and diabetic patients. After inhalation into
potentially is a lethal condition usually tients are immunocompetent, and men are af- the nasal cavity and paranasal sinuses, the
caused by bacterial or fungal invasion com- fected more often than women. The bacteria fungi cause necrotizing vasculitis, thrombo-
plicating sinusitis in patients with poorly are generally considered to gain access to the sis, or infarction of the nose and sinuses and
controlled diabetes or immunosuppression. central nervous system by direct extension can then rapidly extend into the orbits, deep

Fig. 7.—Tolosa-Hunt syndrome in

21-year-old woman with painful
ophthalmoplegia.
A and B, Unenhanced (A) and con-
trast-enhanced (B) axial T1-weighted
images reveal homogeneous infiltrat-
ing lesion (arrows) narrowing carotid
artery in orbital apex and in anterior
cavernous sinus, which shows homo-
geneous intense enhancement.
A B

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A B

Fig. 8.—Inflammatory pseudotumor in 64-year-old woman with right oculomotor

nerve palsy.
A and B, Axial T2-weighted (A) and T1-weighted (B) images show infiltrative mass
(arrows) in right cavernous sinus, sphenoid bone, posterior clival dura, and in-
fratemporal fossa with encasement of carotid artery. Note marked hypointensity
on T2-weighted image.
C, On coronal contrast-enhanced T1-weighted image, lesion is strongly enhanced (solid
arrows). Note thick enhancement of dura (open arrows) along right cerebral convexity.

face, and cranial cavity [4]. The central ner- tributed to paramagnetic elements by hemor- lesions isointense to T1- and T2-weighted
vous system may be invaded directly by ex- rhage or aspergillus fungal colonies, mainly images in the anterior cavernous sinus, the
tension through the skull base or indirectly iron and magnesium [5] (Fig. 6). superior orbital fissure, or the orbital apex
through involvement of the carotid artery and with contrast enhancement [6] (Fig. 7).
cavernous sinus (Fig. 5).
Noninfectious Inflammation Inflammatory Pseudotumor
Aspergillosis Tolosa-Hunt Syndrome Inflammatory pseudotumors are idiopathic
Aspergillosis arises most commonly as a Tolosa-Hunt syndrome is a recurrent pain- inflammatory lesions in which skull base in-
result of hematogenous spread and occasion- ful ophthalmoplegia due to nonspecific gran- volvement is rare. These pseudotumors in-
ally by direct extension of infection from the ulomatous inflammation in the anterior clude a diverse group of lesions characterized
paranasal sinuses, middle ear, or orbit. Most cavernous sinus, superior orbital fissure, or by inflammatory cell infiltration and variable
cases occur in immunocompromised patients orbital apex. The diagnosis is based on find- fibrotic responses according to the chronicity
[5]. As with fungi of the order Mucorales, ings of painful ophthalmoplegia accompa- of the lesion. Typical MR findings include
Aspergillus species tend to invade vessels. nied by variable deficits of the oculomotor soft-tissue lesions infiltrating the skull base
Decreased signal intensity on T1-weighted through the abducens nerves, excellent re- with intracranial dural involvement, bone de-
imaging and very low signal intensity on T2- sponse to corticosteroid therapy, and exclu- struction, iso- to hypointensity on T2-weighted
weighted imaging are characteristic findings sion of other lesions [6]. Reported MR images according to the fibrosis and high cel-
in paranasal sinus aspergillosis and are at- findings include nonspecific inflammatory lularity, and contrast enhancement [7] (Fig. 8).

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 Lee et al.
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A B

Fig. 9.—Bilateral saccular aneurysms of internal carotid arteries in cavernous sinuses in 67-
year-old woman with diplopia.
A, Axial T2-weighted image shows large signal void (arrows) due to aneurysm of internal ca-
rotid artery in both cavernous sinuses.
B, Coronal contrast-enhanced T1-weighted image shows crescent isointense thrombus (black
arrow) in right aneurysm and intense enhancement of left one (white arrows).
C, Digital subtraction angiogram of both internal carotid arteries shows partially thrombosed
aneurysms of internal carotid artery of right cavernous sinus (large arrow) and another aneu-
rysm of internal carotid artery of left one (small arrow).
C

Vascular Lesions eurysms is variable depending on the pres- Carotid–Cavernous Fistula and Dural Arteriovenous Fistula
Aneurysm of the Internal Carotid Artery ence and age of the thrombus and various Carotid–cavernous fistula and dural arterio-
Vascular ectasia and distal internal carotid flow parameters. Diagnosis of a parasellar venous fistula (Fig. 10) may present with simi-
artery aneurysms (Fig. 9) are the most com- aneurysm is clinically important because lar clinical symptoms and signs, and on a
mon nonneoplastic parasellar masses in performing surgery on an aneurysm misdiag- cursory glance, the angiographic appearance
adults. The imaging appearance of these an- nosed as a tumor can have a fatal outcome. may seem to be similar in both conditions.

A B
Fig. 10.—Dural arteriovenous fistula in 61-year-old woman with exophthalmos and ocular pain.
A, Axial T1-weighted image shows enlargement of both cavernous sinuses. Structures other than internal carotid artery that exhibit signal void (arrows) are noted in right
cavernous sinus.
B, Digital subtraction angiogram of right external carotid artery reveals multiple fine feeders from distal branches of right maxillary artery (arrowhead), opacification of
cavernous sinus (large solid arrow), and draining into inferior petrosal (open arrow) and sphenoparietal (small solid arrow) sinuses. Distal internal carotid artery (curved
arrow) and its branches are also opacified.

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 MR Imaging of Cavernous Sinus Syndrome
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A B
Fig. 11.—Perineural spread of adenoid cystic carcinoma of parotid gland in 36-year-old woman with diplopia and left-sided hemifacial pain.
A, Coronal contrast-enhanced T1-weighted image shows strongly enhancing infiltrating mass in left parapharyngeal space (arrows) extending into cavernous sinus
through widened foramen ovale.
B, Contrast-enhanced CT scan obtained at level of parotid glands shows enhancing mass in deep lobe of left parotid gland that is infiltrating into parapharyngeal space
through stylomandibular tunnel (arrows).

A B

Fig. 12.—Cavernous hemangioma (cavernoma) in 56-year-old woman with

severe headache.
A, Coronal T2-weighted image shows well-defined round homogeneous hy-
perintense mass in left cavernous sinus.
B, Coronal T1-weighted image shows isointensity of mass. Note encased lu-
men of internal carotid artery is not narrowed, despite large size of mass.
C, Axial contrast-enhanced T1-weighted image shows intense homoge-
neous enhancement.
C

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 Lee et al.

Carotid–cavernous fistula can result from adenoma, perineural spread of head and neck 2. Schuknecht B, Simmen D, Yuksel C, Valavanis A.
traumatic laceration of the carotid artery or malignancy, or hematogenous spread from Tributary venosinus occlusion and septic cavernous
sinus thrombosis: CT and MR findings. AJNR
from rupture of an aneurysm into the sur- distant lesions (Fig. 11). However, primary
1998;19:617–626
rounding venous sac establishing a direct ar- tumors such as meningioma, neurogenic tu- 3. Funaki B, Rosenblum JD. MR of central nervous
teriovenous fistula between the internal mors, and hemangioma can also arise from system actinomycosis. AJNR 1995;16:1179–1180
Downloaded from www.ajronline.org by 115.178.195.133 on 04/26/18 from IP address 115.178.195.133. Copyright ARRS. For personal use only; all rights reserved

carotid artery and the venous spaces of the the cavernous sinus itself (Fig. 12). 4. Chan LL, Singh S, Jones D, Diaz EM Jr, Gins-
cavernous sinus. However, dural arterio- berg LE. Imaging of mucormycosis skull base os-
venous fistula of the cavernous sinus is most teomyelitis. AJNR 2000;21:828–831
Conclusion 5. Yamada K, Zoarski GH, Rothman MI, Zagardo
easily understood as simply a dural arterio-
Cavernous sinus syndrome can be caused MT, Nishimura T, Sun CCJ. An intracranial as-
venous fistula in a specific location [8]. On
pergilloma with low signal on T2-weighted im-
CT or MR imaging, the diagnosis depends on by various disease entities. Understanding
ages corresponding to iron accumulation.
morphologic changes such as exophthalmos the characteristic clinical features and their Neuroradiology 2001;43:559–561
and enlargement of the superior ophthalmic implications as well as the characteristic im- 6. de Arcaya AA, Cerezal L, Canga A, Polo JM,
veins, cavernous sinus, or extraocular mus- aging findings will assist in the differential Berciano J, Pascual J. Neuroimaging diagnosis of
cles. MR imaging is able to depict flow voids diagnosis focused on this small but complex Tolosa-Hunt syndrome: MRI contribution. Head-
structure, the cavernous sinus. ache 1999;39:321–325
in the involved cavernous sinus.
7. Han MH, Kim MS, Chang KH, Kim KH, Yeon
KM, Han MC. Fibrosing inflammatory pseudotu-
Neoplasm mors involving the skull base: MR and CT mani-
References festations with histopathologic comparison.
The most common neoplastic lesions in 1. van Overbeeke JJ, Jansen JJ, Tulleken CAF. The AJNR 1996;17:515–521
the cavernous sinus are caused by direct inva- cavernous sinus syndrome: an anatomical and clini- 8. Morris P. Practical neuroangiography, 1st ed.
sion of intracranial tumors such as pituitary cal study. Clin Neurol Neurosurg 1988;90:311–319 Baltimore: Williams & Wilkins, 1997:349–350

590 AJR:181, August 2003