What is the management of cavernous sinus thrombosis?

Management of Cavernous Sinus Thrombosis

Anticoagulation with intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin should be initiated immediately upon diagnosis of cavernous sinus thrombosis, even in the presence of intracranial hemorrhage, as this is the principal therapy aimed at preventing thrombus propagation and increasing recanalization. 1, 2, 3

Diagnostic Confirmation

• Diagnosis should be confirmed with MRI with MR venography (preferred) or CT venography if MRI is not readily available 1, 3
• Look for secondary signs such as cerebral swelling, edema, and/or hemorrhage 1
• Catheter angiography may be needed in select cases with high clinical suspicion but negative initial imaging 3

Treatment Algorithm

Antibiotic Therapy (for Septic Cavernous Sinus Thrombosis)

• Initiate high-dose intravenous antibiotics immediately upon diagnosis 1
• Recommended regimen: IV vancomycin 15-20 mg/kg/dose every 8-12 hours (not exceeding 2g per dose) 1
• Consider adding rifampin 600 mg daily or 300-450 mg twice daily to vancomycin 1
• Alternative antibiotics include linezolid 600 mg PO/IV twice daily and TMP-SMX 5 mg/kg/dose IV every 8-12 hours 1
• Continue antibiotic therapy for 4-6 weeks 1
• Blood cultures are positive in up to 70% of cases; common pathogens include Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli 4

Anticoagulation Therapy

• Initiate anticoagulation with either:
  • Intravenous unfractionated heparin (UFH) OR
  • Subcutaneous low-molecular-weight heparin (LMWH) 1, 2, 3
• Continue anticoagulation for at least 3 months 1
• Anticoagulation should be administered even in the presence of intracranial hemorrhage, as the benefits outweigh the risks 1, 2
• Duration of anticoagulation depends on underlying etiology:
  • 3-6 months for transient risk factors 2, 3
  • 6-12 months for unprovoked cavernous sinus thrombosis 2
  • Indefinite (lifelong) anticoagulation for severe thrombophilia or recurrent thrombosis 2, 3
• Recent evidence shows significantly lower mortality in patients receiving anticoagulation (3.3% vs 18%, p=0.022) 5

Surgical Intervention

• Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible 1
• For patients with significant mass effect, surgical evacuation may be necessary while continuing anticoagulation therapy 2
• Decompressive hemicraniectomy may be considered in cases with severe mass effect or neurological deterioration despite medical treatment 2

Monitoring and Follow-up

• All patients should be admitted to a stroke unit or neurocritical care setting for close monitoring 2, 3
• Regular neurological assessment is essential to detect early signs of deterioration 1
• Follow-up imaging should be performed to assess recanalization 1
• If neurological deterioration occurs despite medical treatment, repeat neuroimaging should be performed to assess for increased mass effect 2

Special Considerations

• For suspected fungal etiology (e.g., Aspergillus), voriconazole should be initiated 1
• For possible zygomycosis, an amphotericin B formulation should be started 1
• Patients with hyperglycemia should be carefully monitored when receiving anticoagulation 5
• Investigate underlying prothrombotic conditions as this affects treatment duration 3

Prognosis

• With modern treatment approaches, mortality is approximately 11%, with morbidity around 15% 6
• Early diagnosis and treatment are critical for optimal outcomes 7
• Potential complications include vision loss and other cranial nerve deficits 7