What is the neurosurgery management approach for a patient with Cavernous Sinus Thrombosis (CST) and Streptococcus pneumoniae (S. pneumoniae) meningitis?

Neurosurgical Management of Cavernous Sinus Thrombosis with S. pneumoniae Meningitis

Neurosurgical consultation should be obtained immediately for patients with cavernous sinus thrombosis and meningitis, with the primary role being evaluation for surgical drainage of contiguous infection sources (paranasal sinuses) and monitoring for life-threatening intracranial complications requiring decompressive intervention. 1, 2

Immediate Neurosurgical Consultation Indications

Obtain neurosurgical consultation when any of the following are present:

• Altered mental status or severe headache suggesting intracranial extension 1
• Signs of increased intracranial pressure (worsening consciousness, new focal deficits, seizures) 3, 4
• Severe mass effect on imaging from hemorrhagic venous infarction 1, 3
• Evidence of epidural abscess, subdural empyema, or brain abscess on imaging 1
• Progressive neurological deterioration despite maximal medical therapy 3, 4

Primary Neurosurgical Roles

1. Surgical Source Control

The neurosurgical team should coordinate with otolaryngology for surgical drainage of infected paranasal sinuses, as this is critical for optimal outcomes. 2, 5

• Surgical evaluation for incision and drainage of contiguous sites of infection should occur as soon as the diagnosis is confirmed 2
• Early surgical drainage of purulent exudate in the air sinuses is essential, as medical therapy alone has historically resulted in 30% mortality for cavernous sinus thrombosis 6
• Maxillary sinus lavage and orbital exploration may be required depending on the primary infection source 5

2. Monitoring for Decompressive Surgery Needs

Decompressive hemicraniectomy may be lifesaving in patients with severe mass effect or large intracerebral hemorrhage causing progressive neurological deterioration. 1, 3

• This intervention should be considered when there is severe mass effect on repeated imaging despite adequate anticoagulation and antibiotics 1, 3
• Serial neurological examinations every 4-6 hours are required to detect progression, specifically assessing cranial nerves III, IV, V1, V2, and VI function, visual acuity, and pupillary responses 4
• Repeat imaging within 48-72 hours if clinical deterioration occurs 4

3. Intracranial Pressure Management

Neurosurgical expertise is essential for managing elevated intracranial pressure through medical and potentially surgical means. 3

• Monitor for signs requiring escalation: worsening consciousness, new focal deficits, seizures, and severe mass effect on repeat imaging 3, 4
• All patients require management of seizures if present and control of elevated intracranial pressure 3

Critical Imaging Requirements

Contrast-enhanced CT scan (preferably coronal thin cut) of the head, orbits, and sinuses is essential to confirm intracranial or intraorbital suppurative complications; MRI may be more desirable for intracranial abnormalities. 1

• MRI with MR venography provides superior visualization of cavernous sinus thrombosis extent and associated complications compared to CT 4
• CT with contrast has 97% accuracy for detecting cavernous sinus thrombosis if MRI is unavailable 4
• Imaging should evaluate for epidural abscess, subdural empyema, cerebritis, brain abscess, and meningitis 1

Multidisciplinary Coordination

Consultation with otolaryngology, ophthalmology, infectious disease, and neurosurgery is appropriate for guidance regarding surgical intervention timing and antimicrobial selection. 1

• A multidisciplinary treatment team is beneficial for managing the sequelae of this condition 7
• Neurosurgery should be involved early in the hospital course, not just when complications develop 1

Common Pitfalls to Avoid

The most critical error is delaying neurosurgical consultation until after neurological deterioration has occurred. 1

• Do not wait for "failure of medical management" before involving neurosurgery—early consultation allows for proactive monitoring and rapid intervention if needed 1
• Do not assume anticoagulation alone will prevent progression; surgical source control is equally important 2, 6, 5
• Do not delay surgical drainage of infected sinuses while waiting for antibiotic response; early drainage improves outcomes 6, 5

Prognosis Considerations

With modern management including early surgical intervention, anticoagulation, and appropriate antibiotics, mortality has decreased from historical rates of 30-80% to much lower levels, though permanent neurological deficits remain common. 6, 8

• Recent series show that 9 of 12 patients (75%) recovered without permanent deficits when treated aggressively 8
• However, complications such as blindness can still occur despite optimal treatment 5
• Early diagnosis and treatment are essential for preventing permanent sequelae 7