Management of Cavernous Sinus Thrombosis
Initiate immediate triple therapy with high-dose intravenous antibiotics (vancomycin 15-20 mg/kg every 8-12 hours), anticoagulation (unfractionated heparin or low molecular weight heparin), and surgical drainage of any contiguous infection source. 1
Diagnostic Confirmation
Before initiating treatment, confirm the diagnosis with contrast-enhanced MRI with MR venography, which demonstrates the highest sensitivity (92.5% sensitivity, 100% specificity) for identifying cavernous sinus thrombosis and evaluating for orbital and intracranial complications. 1, 2 If MRI is unavailable or contraindicated in the emergency setting, obtain CT head and orbits with IV contrast using delayed phase imaging or CT venography. 2, 3
Look for secondary signs including cerebral swelling, edema, hemorrhage, proptosis, chemosis, periorbital edema, ptosis, and ophthalmoplegia. 4, 3 Cranial nerve VI palsy (lateral rectus weakness) is the most common cranial nerve finding, though cranial nerves III, IV, and V may also be affected. 3
Immediate Antibiotic Therapy
Start high-dose IV vancomycin 15-20 mg/kg/dose every 8-12 hours (maximum 2g per dose) immediately upon diagnosis, as Staphylococcus aureus is the most common pathogen. 1, 3, 5 Consider adding rifampin 600 mg daily or 300-450 mg twice daily to vancomycin for enhanced coverage. 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 minimum. 1 Blood cultures are positive in up to 70% of cases, so obtain cultures before starting antibiotics but do not delay treatment. 3
For suspected fungal etiology (particularly in immunocompromised patients or those with diabetes), initiate voriconazole for Aspergillus or amphotericin B formulation for possible zygomycosis. 1
Anticoagulation Therapy
Initiate anticoagulation with either IV unfractionated heparin or subcutaneous low molecular weight heparin immediately, even in the presence of intracranial hemorrhage. 4, 1, 6, 2 The presence of hemorrhage related to cavernous sinus thrombosis is NOT a contraindication to anticoagulation, as the benefits of preventing thrombus propagation and increasing recanalization outweigh the risks. 4, 1, 6
Continue anticoagulation for at least 3 months, with duration depending on underlying etiology: 1, 6
- Transient reversible risk factors (infection): 3-6 months 6
- Idiopathic or low-risk thrombophilia: 6-12 months 6
- High-risk inherited thrombophilia or recurrent events: Consider lifelong anticoagulation 6
Surgical Intervention
Perform urgent surgical evaluation for incision and drainage of contiguous sites of infection, including sphenoid sinusitis, mastoiditis, facial abscesses, or orbital complications. 1, 7 Functional endonasal sinus surgery to drain the primary sites of infection significantly improves outcomes when combined with antibiotic therapy. 7
Monitoring and Follow-up
Admit all patients to a stroke unit or intensive care setting for close neurological monitoring to detect early signs of deterioration. 6 Perform regular neurological assessments focusing on cranial nerve function, level of consciousness, and signs of increased intracranial pressure. 1, 6
Obtain follow-up imaging with CTV or MRV at 3-6 months after diagnosis to assess recanalization of the occluded sinuses in stable patients. 6, 2 Perform early follow-up imaging if patients develop persistent or evolving symptoms despite medical treatment, suggesting thrombus propagation. 4, 6
Critical Pitfalls to Avoid
Do not withhold anticoagulation due to presence of intracranial hemorrhage—this is a common and potentially fatal error. 4, 1, 6 Do not delay antibiotics while awaiting culture results, as mortality remains 30% even with treatment. 3, 5 Do not miss the primary source of infection requiring surgical drainage, as medical therapy alone has suboptimal outcomes. 1, 7