What is the treatment for cavernous sinus thrombosis?

Treatment of Cavernous Sinus Thrombosis

Immediate therapeutic anticoagulation with heparin (IV unfractionated heparin or subcutaneous low molecular weight heparin) is the cornerstone of treatment for cavernous sinus thrombosis and should be initiated upon diagnosis if no major contraindications are present. 1

Comprehensive Management Approach

Anticoagulation Therapy

• Initial anticoagulation with heparin (IV unfractionated or LMWH)
• Transition to vitamin K antagonists (target INR 2.5) for long-term management
• Duration: 3-12 months depending on underlying etiology
  • 3 months for initial event
  • Longer duration for high-risk inherited thrombophilia or recurrent thrombotic events 1
• Anticoagulation should be administered even in the presence of hemorrhagic changes 1

Antimicrobial Therapy

• Broad-spectrum antibiotics targeting common causative organisms:
  • Staphylococcus aureus
  • Streptococcal species (including Streptococcus milleri)
  • Oral anaerobes
  • Gram-negative bacilli 1, 2
• Antifungal coverage (voriconazole or amphotericin B) if invasive fungal sinusitis is suspected 1

Surgical Interventions

• Drainage of identified source of infection (e.g., orbital abscess, dental extraction) 1, 3
• Decompression for severe mass effect
• Urgent intervention for infectious sources 1

Adjunctive Therapies

• Corticosteroids (e.g., methylprednisolone) if significant inflammation or edema is present 1, 3
• Management of intracranial hypertension if present 1
• Thrombolytic therapy may be considered in specific circumstances:
  • Superior vena cava thrombosis with poorly tolerated vena cava syndrome
  • Massive thrombosis with severe symptoms
  • Recent thrombus (less than 10 days old)
  • Low bleeding risk 1

Diagnostic Approach

Imaging

• Contrast-enhanced MRI with MR venography is the gold standard
  • Highest sensitivity for cavernous sinus thrombosis
  • Key findings: absence of flow void, altered signal intensity, T2 hypointensity, central isodense lesion with surrounding enhancement
  • T2*-weighted/gradient echo/susceptibility-weighted sequences improve diagnostic accuracy 1
• CT venography with IV contrast as an alternative when MRI is unavailable
  • Findings include hyperdensity of the cavernous sinus on non-contrast CT and "empty delta" sign on contrast-enhanced images 1, 2

Clinical Monitoring

• Close neurological monitoring during acute phase
• Follow-up imaging with MRV or CTV at 3-6 months to assess recanalization
• Earlier follow-up imaging if symptoms persist or worsen despite treatment
• Consider endovascular therapy or decompressive hemicraniectomy for patients with neurological deterioration despite initial treatment 1

Common Pitfalls and Caveats

• Delayed diagnosis can significantly increase morbidity and mortality; early recognition and treatment are critical 1, 2
• Relying solely on non-contrast CT can lead to missed diagnoses, as only 30% of non-contrast head CTs are abnormal in cerebral venous thrombosis 1
• Normal anatomic variants (asymmetrical lateral sinuses, arachnoid granulations) can be misinterpreted as thrombosis 1
• Patients may present with somnolence or confusion without obvious focal neurological deficits, especially in elderly patients 1
• Inadequate source control and insufficient anticoagulation can worsen outcomes 1
• Overlooking fungal causes, particularly in immunocompromised patients, can lead to inadequate treatment 1
• Special consideration needed for pregnant patients, who may require coordinated care including obstetric management 3

Despite advances in treatment, cavernous sinus thrombosis remains associated with significant morbidity, with many patients experiencing neurological sequelae even with prompt treatment 4.