Initial Management of Cavernous Sinus Thrombosis
The initial management of cavernous sinus thrombosis (CST) should include immediate administration of broad-spectrum intravenous antibiotics and anticoagulation with either intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin, even in the presence of hemorrhagic lesions. 1, 2
Diagnosis and Imaging
- Diagnosis of CST requires neuroimaging, with MRI with MR venography being the preferred initial imaging modality due to its superior sensitivity for detecting venous thrombosis 2
- CT venography can be used if MRI is not readily available in emergency settings, showing the characteristic "empty delta" sign (lack of enhancement within the affected venous structure) 3, 1
- Gradient echo T2 susceptibility-weighted images combined with MR venography improve diagnostic accuracy for detecting thrombosis 2
- Unenhanced CT may show increased density and distension of the thrombosed sinus or vein, but is less sensitive than MRI for early detection 3
- Catheter cerebral angiography may be necessary in patients with inconclusive CTV or MRV results but high clinical suspicion 2
Initial Treatment Algorithm
Antibiotic Therapy
- Start broad-spectrum intravenous antibiotics immediately to cover the most common causative organisms: Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli 1, 4
- Blood cultures should be obtained before initiating antibiotics, as they are positive in up to 70% of cases 1
- Antibiotics should target the likely source of infection (sinusitis, dental infection, facial infection) 5
Anticoagulation Therapy
- Initiate anticoagulation with either intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin concurrently with antibiotics 2, 6
- The presence of intracerebral hemorrhage related to the thrombosis is NOT a contraindication to anticoagulation 6, 2
- Early anticoagulation therapy reduces morbidity (including blindness, stroke, ophthalmoplegia, and hypopituitarism) compared to delayed or inadequate use 7
- Anticoagulation prevents thrombus propagation, increases the chance of recanalization, and reduces mortality and severe disability 6
Management of Complications
- For elevated intracranial pressure and significant white matter edema causing mass effect, dexamethasone (4-8 mg/day oral or IV) may be considered 2
- However, dexamethasone should not be used routinely in all cases, particularly in asymptomatic patients without significant mass effect 6
- Seizures should be treated aggressively with antiepileptic medications 2
- In cases with sphenoid sinusitis as the source, surgical drainage may be necessary 5
Hospitalization and Monitoring
- All patients should be admitted to a specialized unit for close monitoring 2
- Early specialist consultation (infectious disease, neurology, neurosurgery, ophthalmology) is recommended 1
- Monitor for progression of neurological symptoms, including cranial nerve palsies (particularly CN III, IV, V, and VI) 1, 4
- Regular assessment of inflammatory markers can help track response to treatment 1
Duration of Treatment
- Antibiotic therapy should continue for at least 2-4 weeks, guided by clinical response and inflammatory markers 4
- Anticoagulation duration depends on underlying risk factors:
Common Pitfalls and Considerations
- Delayed diagnosis is common due to the rarity of the condition and variable presentation 4
- Long-term use of dexamethasone (>3 weeks) is associated with significant toxicity and should be avoided 2
- Follow-up imaging at 3-6 months is recommended to assess recanalization of the occluded veins/sinuses 2
- Early follow-up imaging is recommended in patients with persistent or evolving symptoms despite medical treatment 2
- Despite modern treatment, morbidity remains high, with many patients experiencing neurological sequelae, emphasizing the need for prompt recognition and treatment 4