What is the diagnosis and treatment for cavernous sinus thrombosis (CST)?

From the Guidelines

Cavernous sinus thrombosis is a serious medical emergency requiring immediate hospitalization and treatment, with anticoagulation therapy with heparin or low molecular weight heparin (LMWH) recommended to be started immediately after diagnosis, even in the presence of intracranial hemorrhage. The condition involves blood clot formation in the cavernous sinus, a cavity at the base of the brain that contains critical nerves and blood vessels. According to the most recent guidelines, anticoagulation should be initiated as soon as possible, regardless of the presence of hemorrhagic conversion 1.

Clinical Presentation

The clinical presentation of cavernous sinus thrombosis can vary, but common symptoms include headache, fever, and signs of increased intracranial pressure such as papilledema and diplopia due to sixth nerve palsy. Focal neurological signs and symptoms referable to the affected region may also occur, including hemiparesis and aphasia. The diagnosis is typically based on clinical suspicion and imaging confirmation, with MRI and MRV being the preferred imaging modalities 1.

Treatment Approach

Treatment consists of anticoagulation therapy to prevent clot propagation, and high-dose intravenous antibiotics may be considered if there is suspicion of an infectious cause, such as sinusitis or facial infections. The choice of antibiotics should be guided by culture results, but broad-spectrum coverage with vancomycin, ceftriaxone, and metronidazole may be initiated empirically. Surgical drainage of any identified source of infection is also crucial.

Anticoagulation Therapy

The use of anticoagulation with heparin or LMWH is recommended, regardless of the presence of hemorrhagic conversion, as it has been shown to improve outcomes in patients with cerebral venous sinus thrombosis 1. The duration of anticoagulation therapy is typically between 3 to 12 months, depending on the underlying cause and the presence of any contraindications.

Key Considerations

• Prompt initiation of anticoagulation therapy is critical in the management of cavernous sinus thrombosis.
• Imaging confirmation with MRI and MRV is essential for diagnosis.
• Infectious causes should be identified and treated appropriately.
• Surgical drainage may be necessary for source control in cases of infection.
• Monitoring for complications, such as worsening neurological deficits or signs of increased intracranial pressure, is crucial.

From the Research

Definition and Overview

• Cavernous sinus thrombosis (CST) is a rare but devastating disease process that may be associated with significant long-term patient morbidity or mortality 2.
• It is a potentially deadly thrombophlebitic disease involving the cavernous sinuses, with a high rate of morbidity and mortality 3.

Causes and Risk Factors

• The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST 3.
• Other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications 3.
• Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies 3.

Symptoms and Diagnosis

• The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes) 3.
• Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy, and other CNs that may be affected include III, IV, and V 3.
• Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases 3.
• Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity 3.

Treatment and Management

• Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation 3.
• Anticoagulation has been shown to improve mortality in patients with CST, with heparin being the most frequently used initial agent 4.
• Early anticoagulation therapy may reduce morbidity among survivors, including blindness, stroke, ophthalmoplegia, hypopituitarism, focal seizures, and vascular steal syndrome 5.
• Surgical intervention, such as maxillary sinus lavage and orbital exploration, may be necessary in conjunction with anticoagulation therapy and broad-spectrum intravenous antibiotics 6.