What is the management of sigmoid sinus thrombosis (SST)?

From the Guidelines

Management of sigmoid sinus thrombosis requires prompt anticoagulation therapy with low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg subcutaneously twice daily, followed by oral anticoagulation with warfarin (target INR 2-3) or direct oral anticoagulants like rivaroxaban 15-20 mg daily for 3-6 months. The decision to initiate anticoagulation is based on the guidelines provided by the American Heart Association/American Stroke Association, which recommend anticoagulation as the principal therapy for cerebral venous thrombosis (CVT), including sigmoid sinus thrombosis, to prevent thrombus propagation and increase recanalization 1.

The use of anticoagulation in CVT is supported by studies that have shown its effectiveness in reducing the risk of death and dependency, even in patients with intracranial bleeding 1. The guidelines suggest that anticoagulation should be initiated as soon as possible, regardless of the presence of hemorrhagic conversion, and that the duration of anticoagulation should be individualized based on the underlying etiology and the presence of risk factors for recurrence.

In addition to anticoagulation, patients with sigmoid sinus thrombosis may require antibiotics if the thrombosis is associated with infection, and surgical intervention may be necessary in cases with significant mastoid or middle ear infection. Patients should be monitored with serial imaging (MRI/MRV) to assess thrombus resolution, and supportive care should include pain management, hydration, and treatment of increased intracranial pressure if present.

The management of sigmoid sinus thrombosis should be individualized, taking into account the patient's underlying medical conditions, the presence of risk factors for recurrence, and the potential benefits and risks of anticoagulation therapy. The goal of treatment is to prevent further thromboembolic events, reduce the risk of death and dependency, and improve quality of life.

Key points in the management of sigmoid sinus thrombosis include:

• Prompt initiation of anticoagulation therapy with LMWH or oral anticoagulants
• Individualization of anticoagulation duration based on underlying etiology and risk factors
• Use of antibiotics if thrombosis is associated with infection
• Surgical intervention in cases with significant mastoid or middle ear infection
• Monitoring with serial imaging to assess thrombus resolution
• Supportive care to manage pain, hydration, and increased intracranial pressure.

From the Research

Management of Sigmoid Sinus Thrombosis

• The management of sigmoid sinus thrombosis typically involves a combination of surgical and medical treatments, including antibiotics, anticoagulation therapy, and mastoidectomy 2, 3, 4.
• Anticoagulation therapy has been shown to be a safe treatment option when administered correctly, with low molecular weight heparin being a commonly used anticoagulant 3, 4.
• The role of anticoagulation in the treatment of sigmoid sinus thrombosis is still debated, with some studies suggesting that it may aid in recanalization of the affected sinus, while others have found that withholding anticoagulation in selected patients is reasonable 2, 5.
• Surgical treatment, including mastoidectomy and thrombectomy, may be necessary in some cases, particularly when there is evidence of complications such as abscess formation or sepsis 3, 6, 4.
• Imaging studies, such as computed tomography and magnetic resonance imaging, are important for diagnosing and monitoring sigmoid sinus thrombosis, and can help guide treatment decisions 5, 4.
• The use of anticoagulants, such as low molecular weight heparin, has been found to be safe and effective in pediatric patients with otogenic sigmoid sinus thrombosis 3.

Treatment Outcomes

• Recanalization of the sigmoid sinus has been reported in patients treated with anticoagulation therapy and mastoidectomy, as well as in those treated conservatively 3, 4.
• The outcomes of patients with sigmoid sinus thrombosis are generally good, with most patients experiencing complete resolution of symptoms and signs of infection 2, 3, 6, 4.
• However, some patients may experience persistent symptoms, such as headaches and otorrhea, despite treatment 2, 5.

Diagnosis and Presentation

• Sigmoid sinus thrombosis typically presents with symptoms such as headache, neck stiffness, fever, otalgia, and postauricular pain 6, 4.
• The diagnosis of sigmoid sinus thrombosis is often made using a combination of clinical presentation, imaging studies, and laboratory tests 5, 4.