Diagnosis:
This is a clinical diagnosis. Dysfunction of cranial nerves III, IV, and VI, and the superior divisions of cranial nerve V.
Investigations to consider:
Blood tests:
- FBC, U&E, fasting Glucose
- Vasculitic screen, ESR, CRP, ANCA, ANA, ENA
- SPEP, ACE
- Tests for infections: Borrelia serology, HIV
MRI pre and post contrast:
- Pituitary tumors, meningioma, metastasis
- Aneurysms: flow voids, hypointense
If vascular lesion is suspected, CTA:
- Carotid siphon aneurysm
- Carotid cavernous fistula CCF: opacification of cavernous sinuses
- Cavernous sinus thrombosis: filling defects during venous phase
2nd line, Catheter angiography: direct vs. indirect (meningeal feeding) carotid cavernous fistula CCF
LP, CSF analysis
Biopsy
Causes of cavernous sinus syndrome:
- Cavernous sinus infection
- Tumor
- Internal carotid artery aneurysms
- Wegener’s granulomatosis
- Tolosa hunt syndrome