What is the treatment for Cavernous sinus thrombosis?

From the Guidelines

The treatment of cavernous sinus thrombosis typically involves immediate administration of anticoagulation with heparin or low molecular weight heparin (LMWH), as it is associated with a reduced risk of death and dependency, regardless of the presence of hemorrhagic conversion 1. The use of anticoagulation in the setting of cerebral venous thrombosis (CVT) is recommended, based on the results of two randomized trials that demonstrated a trend towards improved outcomes with anticoagulation therapy 1.

• The first trial compared dose-adjusted unfractionated heparin (UFH) with placebo and found that heparin therapy was superior, with 8 out of 10 patients recovering completely and only 2 patients having mild neurological deficits, compared to 1 patient with complete recovery and 3 deaths in the placebo group 1.
• A more recent and slightly larger randomized study compared nadroparin (90 anti–Xa U/kg twice daily) with placebo and found that 13% of patients in the anticoagulation group and 21% in the placebo group had poor outcomes, although the difference was not statistically significant 1. The American Heart Association/American Stroke Association guidelines recommend the use of anticoagulation with heparin or LMWH in the acute setting of CVT, regardless of the presence of hemorrhagic conversion, and suggest that the duration of anticoagulation therapy should be individualized, with periods of 3-12 months or lifelong anticoagulation depending on the underlying etiology 1.
• The proposed algorithm for the management of CVT includes initiation of anticoagulation with IV heparin or SC LMWH if there are no major contraindications, and continuation of oral anticoagulation for 3-12 months or lifelong according to the underlying etiology 1. It is essential to note that the evidence for the use of anticoagulation in CVT is based on limited randomized trial data, and the guidelines are based on expert opinion and observational studies 1. However, the use of anticoagulation with heparin or LMWH is the recommended treatment for cavernous sinus thrombosis, as it is associated with improved outcomes and reduced risk of death and dependency 1.

From the Research

Treatment Overview

The treatment for Cavernous sinus thrombosis (CST) typically involves a combination of the following:

• Intravenous antibiotic therapy 2, 3, 4
• Surgical intervention, such as endonasal sinus surgery or endoscopic drainage of the infected sinuses 2, 3, 4
• Anticoagulation therapy to reduce morbidity among survivors 3, 5, 4
• Corticosteroids may be administered in some cases 2

Medical Treatment

• High-dose intravenous antibiotics, such as ceftriaxone and metronidazole, are commonly used to treat CST 2, 3
• Anticoagulation therapy, such as heparin, may be used to reduce the risk of further thrombosis and improve outcomes 5, 4

Surgical Treatment

• Endonasal sinus surgery or endoscopic drainage of the infected sinuses may be necessary to remove the source of infection 2, 3, 4
• Surgical intervention may also involve drainage of abscesses or debridement of infected tissue 4

Supportive Care

• Patients with CST may require supportive care, such as mechanical ventilation, to manage complications such as adult respiratory distress syndrome 4
• Close monitoring and follow-up are necessary to manage potential long-term sequelae, such as neurologic deficits or visual loss 3, 4