Cavernous sinus

CAVERNOUS SINUS

Q. 1 Which of the following structure does not pass through Cavernous sinus:
 A Middle Cerebral artery
 B Internal Carotid artery
 C Abducens nerve
 D Trochlear nerve
Q. 1 Which of the following structure does not pass through Cavernous sinus:
 A Middle Cerebral artery
 B Internal Carotid artery
 C Abducens nerve
 D Trochlear nerve
Ans. A

Explanation:

Middle Cerebral artery (Ref: B.D. Chaurasia, 3rd Ed, Vol lll/Pg 72, 73) Relation of Cavernous sinus:

A.   Structures outside the sinus:

(a)  Superiorly: Optic tract, internal carotid artery, & anterior perforated substance

(b)  Inferiorly: Foramen lacerum & junction of greater wing of sphenoid

(c)  Medially: Hypophysis cerebri & sphenoid sinus

(d)  Laterally: Temporal lobe with uncus

(e)  Anteriorly: Superior orbital fissure & apex of the orbit

(f) Posteriorly: Apex of petrous temporal bone & crus cerebri of midbrain

B. Structures in the lateral wall of sinus:

(a)  Occulomotor nerve

(b) Trochlear nerve

(c) Ophthalmic nerve

(d) Maxillary nerve

(e) Trigeminal nerve

 

C. Structures passing through the centre of sinus:

(a)  Internal carotid artery     (b)  Abducens nerve


Q. 2

Tributary of the cavernous sinus includes all of the following, EXCEPT?

 A

Superior petrosal sinus

 B

Inferior petrosal sinus

 C

Superficial middle cerebral vein

 D

Deep middle cerebral vein

Q. 2

Tributary of the cavernous sinus includes all of the following, EXCEPT?

 A

Superior petrosal sinus

 B

Inferior petrosal sinus

 C

Superficial middle cerebral vein

 D

Deep middle cerebral vein

Ans. D

Explanation:

Deep Middle cerebral veins drain into the basal veins which drain into the Great cerebral veins that terminate in the straight sinus. Deep Middle cerebral veins neither form direct incoming channels nor direct draining channels for the cavernous sinuses.


Q. 3

A 46-year-old man sustains a spider bite on his upper eyelid, and an infection develops. The physician is very concerned about spread of the infection to the dural venous sinuses of the brain via emissary veins. With which of the following dural venous sinuses does the superior ophthalmic vein directly communicate?

 A

Cavernous sinus

 B

Occipital sinus

 C

Sigmoid sinus

 D

Superior petrosal sinus

Q. 3

A 46-year-old man sustains a spider bite on his upper eyelid, and an infection develops. The physician is very concerned about spread of the infection to the dural venous sinuses of the brain via emissary veins. With which of the following dural venous sinuses does the superior ophthalmic vein directly communicate?

 A

Cavernous sinus

 B

Occipital sinus

 C

Sigmoid sinus

 D

Superior petrosal sinus

Ans. A

Explanation:

The anterior continuation of the cavernous sinus, the superior ophthalmic vein, passes through the superior orbital fissure to enter the orbit. Veins of the face communicate with the superior ophthalmic vein. Because of the absence of valves in emissary veins, venous flow may occur in either direction. Cutaneous infections may be carried into the cavernous sinus and result in a cavernous sinus infection which may lead to an infected cavernous sinus thrombosis. The cavernous sinus is located lateral to the pituitary gland and contains portions of cranial nerves III, IV, V1, V2 and VI, and the internal carotid artery.


Q. 4

All of the following cranial nerves traverse through the cavernous sinus, EXCEPT?

 A

Occulomotor

 B

Trochlear

 C

Maxillary division of trigeminal

 D

Abducens

Q. 4

All of the following cranial nerves traverse through the cavernous sinus, EXCEPT?

 A

Occulomotor

 B

Trochlear

 C

Maxillary division of trigeminal

 D

Abducens

Ans. C

Explanation:

The cranial nerves traversing the cavernous sinus are oculomotor, trochlear, abducens and ophthalmic division of the trigeminal nerve together with trigeminal ganglion.
 
Cavernous sinuses are seen on either side of the sella turcica. They receive drainage from  ophthalmic and facial veins and blood leaves the cavernous sinuses via the petrosal sinuses.

Q. 5

Which of these is NOT a tributary of cavernous sinus?

 A

Sphenoparietal sinus

 B

Superior petrosal sinus

 C

Superficial middle cerebral vein

 D

Inferior ophthalmic vein

Q. 5

Which of these is NOT a tributary of cavernous sinus?

 A

Sphenoparietal sinus

 B

Superior petrosal sinus

 C

Superficial middle cerebral vein

 D

Inferior ophthalmic vein

Ans. B

Explanation:

Tributaries of the cavernous sinus:
  • Superior ophthalmic vein (a branch from the inferior ophthalmic vein)
  • Superficial middle cerebral vein
  • Inferior cerebral veins
  • Sphenoparietal sinus
The central retinal vein and frontal tributary of the middle meningeal vein sometimes drain into it. 
 
Also know:
 
The sinus drains to the transverse sinus via the superior petrosal sinus; to the internal jugular vein via the inferior petrosal sinus and a plexus of veins on the internal carotid artery; to the pterygoid plexus by veins traversing the emissary sphenoidal foramen, foramen ovale and foramen lacerum; and to the facial vein by the superior ophthalmic vein.

Q. 6

A 46 year old man sustains a spider bite on his upper eyelid, and an infection develops. The physician is very concerned about spread of the infection to the dural venous sinuses of the brain via emissary veins. With which of the following dural venous sinuses does the superior ophthalmic vein directly communicate?

 A

Cavernous sinus

 B

Occipital sinus

 C

Sigmoid sinus

 D

Superior petrosal sinus

Q. 6

A 46 year old man sustains a spider bite on his upper eyelid, and an infection develops. The physician is very concerned about spread of the infection to the dural venous sinuses of the brain via emissary veins. With which of the following dural venous sinuses does the superior ophthalmic vein directly communicate?

 A

Cavernous sinus

 B

Occipital sinus

 C

Sigmoid sinus

 D

Superior petrosal sinus

Ans. A

Explanation:

The anterior continuation of the cavernous sinus, the superior ophthalmic vein, passes through the superior orbital fissure to enter the orbit. Veins of the face communicate with the superior ophthalmic vein. Because of the absence of valves in emissary veins, venous flow may occur in either direction. Cutaneous infections may be carried into the cavernous sinus and result in a cavernous sinus infection which may lead to an infected cavernous sinus thrombosis. The cavernous sinus is lateral to the pituitary gland and contains portions of cranial nerves III, IV, V1, V2 and VI, and the internal carotid artery.
  • The occipital sinus is at the base of the falx cerebelli in the posterior cranial fossa. It drains into the confluence of sinuses.
  • The sigmoid sinus is the anterior continuation of the transverse sinus in the middle cranial fossa. The sigmoid sinus passes through the jugular foramen and drains into the internal jugular vein.
  • The superior petrosal sinus is at the apex of the petrous portion of the temporal bone and is a posterior continuation of the cavernous sinus. The superior petrosal sinus connects the cavernous sinus with the sigmoid sinus.

Q. 7

Which is a direct content of cavernous sinus :

 A

Ophthalmic division of trigeminal nerve

 B

Trochlear nerve

 C

Abducent nerve

 D

Occulomotor nerve

Q. 7

Which is a direct content of cavernous sinus :

 A

Ophthalmic division of trigeminal nerve

 B

Trochlear nerve

 C

Abducent nerve

 D

Occulomotor nerve

Ans. C

Explanation:

C i.e. Abducent nerve


Q. 8

The danger area of the face is so called because of the connection of the facial veins to the cavernous sinus through the

 A

Transverse facial vein

 B

Superior ophthalmic vein

 C

Maxillary vein

 D

Ethmoidal vein

Q. 8

The danger area of the face is so called because of the connection of the facial veins to the cavernous sinus through the

 A

Transverse facial vein

 B

Superior ophthalmic vein

 C

Maxillary vein

 D

Ethmoidal vein

Ans. B

Explanation:

B i.e. Superior ophthalmic vein


Q. 9

Veins communicating the cavernous sinus to pterygoid plexus pass through fossa of :

 A

Scapra

 B

Vesalius

 C

Ovale

 D

Langer

Q. 9

Veins communicating the cavernous sinus to pterygoid plexus pass through fossa of :

 A

Scapra

 B

Vesalius

 C

Ovale

 D

Langer

Ans. B

Explanation:

 

  • Foramen Vesalius is an inconstant foramen that gives passage to an emissary vein that connects pterygoid venous plexus with cavernous sinus (vein of vesalius)Q. It is also k/a sphenoidal emissary foramen as its seen in the great wing of sphenoid, medial to foramen ovale, opposite the root of pterygoid process. When present it opens below near scaphoid fossa (in the pterygoid process of sphenoid & gives origin to tensor vali patatini)

Q. 10

Paralysis of 3rd, 4th, 6th nerves with involvement of ophthalmic division of 5th nerve, localizes the lesion 

 A

Cavernous sinus.

 B

Apex of orbit.

 C

Brainstem

 D

Base of skull.

Q. 10

Paralysis of 3rd, 4th, 6th nerves with involvement of ophthalmic division of 5th nerve, localizes the lesion 

 A

Cavernous sinus.

 B

Apex of orbit.

 C

Brainstem

 D

Base of skull.

Ans. A

Explanation:

A i.e. Cavernous sinus

Abrupt (sudden/ very rapid) onset of marked systemic features (high grade fever) with proptosis, chemosis especially with prostration, sequential ophthalmoplegia (i.e. initial lateal gaze involvement), bilateral involvement and mastoid edemaQ strongly suggest the diagnosis of cavernous sinus thrombosis.

– In cavernous sinus, the ophthmic division of trigeminal (Vi)nerve picks up sympathetic fibers from cavernous plexus. These are for dilator papillae muscle. Vi divides just posterior to superior orbital fissure into 3 branches (lacrimal nerve, frontal nerve, nasociliary nerve), which pass through superior orbital fissureQ

Lesions of cavernous sinus e.g. thrombosis, rupture of aneurysm of internal carotid artery at may lead to paralysis of 3rd 4th, 5th and 6th nerve Q

 

Feature

Cavernous Sinus Thrombosis

Orbital Cellultis     

Orbital Apex Syndrome     

Arise from

– Most septic CST arise from

– Exension of inflammation

– < 1% of orbital cellulitis result in

 

sphenoid or ethmoid sinuses >>

from neighbouring tissues esp

OAS; howeve, >50% of these

 

dental, facial & ear infection by

gram positive bacteria

sinuses (mc ethmoid); eyelid,

eyeball, face etc or

occur in patient with diabetes

meltitus and most frequently

 

– Aseptic thrombosis (rare) is

penetrating injuries &

d/t rhinocerebral

 

caused by conditions that 1/t

surgeries

mucormycosis.

 

venous thrombosis eg

Bacterial OC is more common

– Ketoacidosis is most important

 

polycythemia, sickle cell anemia,

in children whereas, fungal

risk factor b/o lack of inhibitory

 

(vasculidities), trauma,

neurosurgery, pregnancy & oral

condraceptive use.

(mucor or Aspergillus) affect

diabetic (ketoacidosis) &

immune compromised

activity against Rhizopus in

serum.

Involve

Cavernous sinus i.e.

– All orbital contents may be

– Superior orbital fissure

 

– 6th CN & carotid plexus of

involved and may evolve into

transmitting 3rd,4th, 6th and Vi

 

sympathetic nerves run

through the substance

orbital abscess

cranial nerves

– Optic canal transmitting optic

 

3rd,4th,ophthalmic (Vi) and

maxillary (V2) division of 5th

 

(2nd) cranial nerve

 

CN and trigeminal ganglion lie

in lateral wall

 

 

Onset & progression

Abrupt / violent /Very RapidQ

Slower (relatively)

Slower (relatively)

Systemic Features

MarkedQ (fever, headache,

nausea, vomiting)

Mild (less prominent)

Mild (less prominent)

Mastoid edema

DiagnosticQ (Present)

Absent

Absent

Laterality

Bilateral (in >50%), although

initially unilateral

Unilateral

Unilateral

Proptosis & Chemosis

Marked (with eye pain)

Marked (with severe eye pain)

Mild to moderate (do not always

complain of pain)

Vision

Not affected in early stagesQ

May lost early if retrobulbar

Lost in early stages d/t optic

(2″ CN)

 

optic neuritis or compression

develop

nerve involvement (RAPD)

present

Ophthalmoplegia

Sequential (beginning with 6th

Concurrent & complete

Concurrent & complete external

(3,4,6 CN)

nerve) and completeQ. Initial

external ophthalmoplegia

ophthalmoplegia involving 3rd,4th

 

lateral rectus (gaze) palsyQ is d/ t

early involvement of 6th nerve in

substance of CS.

involving 3rd,4th & 6th nerve

& 6th nerve

Irigeminal (V) nerve

Opthalmic (V1) and maxillary

Opthalmic (V1) division involved

(5 CN)

(V2) division involved

 

(= decreased corneal sensation)

Clinical Features

Abrupt onset marked periorbital

Signs of anterior eye

Visual loss (2″ CN) and

 

edema, orbital congestion

(chemosis), proptosis, adnexal

involvement (chemosis,

edema) are usually out of

ophthalmoplegia are out of

proportion and often precede

 

edema, eye pain, ptosis and

ophthalmoplegia (involving 3rd,

4th, 6th cm

CN) with involvement of

VI & Vz.

proportion to ophthalmoplegia

at least initially

signs of anterior eye involvement,

such as proptosis periorbital

(adnexel) edema, and orbital

congestion


Q. 11

Veins not involved in spreading infection to cavernous sinus from danger area of face:

 A

Lingual vein

 B

Pterygoid plexus

 C

Facial vein

 D

Ophthalmic vein

Q. 11

Veins not involved in spreading infection to cavernous sinus from danger area of face:

 A

Lingual vein

 B

Pterygoid plexus

 C

Facial vein

 D

Ophthalmic vein

Ans. A

Explanation:

 

Dangerous area of face

Dangerous area of face includes upper lip and anteroinferior part of nose including the vestibule. This area freely communicates with the cavernous sinus through a set of valveless veins, anterior facial vein and superior ophthalmic vein. Any infection of this area can thus travel intracranially leading to meningitis and cavernous sinus thrombosis.

Vein draining dangerous area                                                                                                                  

  • Through facial veins communicating with ophthalmic veins (both having no valve)
  • Through the pterygoid plexus of veins which communicate with facial vein on one hand and the cavernous sinus through emissary vein on the other hand.

 

Deep connections of the facial vein include:

  • A communication between the supraorbital and superior ophthalmic veins.
  • Another with the pterygoid plexus through the deep facial vein which passes backwards over the buccinator. The facial vein communicates with the cavernous sinus through these connections. Infections from the face can spread in a retrograde direction and cause thrombosis of the cavernous sinus. This is specially likely to occur in the presence of infection in the upper lip and in the lower part of the nose. This area is, therefore, called the dangerous area of the face.

Q. 12

All of the following structures are located in the lateral wall of the cavernous sinus except:

 A

Abducent nerve

 B

Oculomotor nerve

 C

Trochlear nerve

 D

Ophthalmic nerve

Q. 12

All of the following structures are located in the lateral wall of the cavernous sinus except:

 A

Abducent nerve

 B

Oculomotor nerve

 C

Trochlear nerve

 D

Ophthalmic nerve

Ans. A

Explanation:

Ans. Abducent nerve



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