Cavernous Sinus Thrombosis Treatment & Management
- Author: Rahul Sharma, MD, MBA, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Emergency Department Care
- The mainstay of therapy for cavernous sinus thrombosis is early and aggressive antibiotic administration. Although S aureus is the usual cause, broad-spectrum coverage for gram-positive, gram-negative, and anaerobic organisms should be instituted pending the outcome of cultures.
- Empiric antibiotic therapy should include a penicillinase-resistant penicillin plus a third- or fourth-generation cephalosporin. If dental infection or other anaerobic infection is suspected, an anaerobic coverage should also be added.
- IV antibiotics are recommended for a minimum of 3-4 weeks.
- Controversy exists on the use of anticoagulation for cavernous sinus thrombosis. Because of the rarity of this syndrome, no prospective trials have been performed on the use of anticoagulation for CST. Some retrospective studies have shown a decrease in mortality and clot propagation by anticoagulation. A Cochrane review found 2 small trials involving 79 patients who were treated with anticoagulants. Limited evidence suggests anticoagulant drugs are probably safe and may be beneficial for people with sinus thrombosis.[5] Therefore, anticoagulation with heparin should be considered since the goal is to prevent further thrombosis and to reduce the incidence of septic emboli. Heparin is contraindicated in the presence of intracerebral hemorrhage or other bleeding diathesis.
- Locally administered thrombolytics have also been used in the treatment of CST. However, use of thrombolytics should be considered experimental and only for severe refractory cases.[1]
- Corticosteroids may help to reduce inflammation and edema and should be considered as an adjunctive therapy. They should be instituted after antibiotic coverage. When the course of CST leads to pituitary insufficiency, however, corticosteroids definitely are indicated to prevent adrenal crisis. Dexamethasone or hydrocortisone should be considered.
- Surgery on the cavernous sinus is technically difficult and has never been shown to be helpful. The primary source of infection should be drained, if feasible (eg, sphenoid sinusitis, facial abscess). It is important to recognize the infected sphenoid sinus early and to prevent spread of the infection to the cavernous sinus.
Consultations
- If drainage is indicated, make arrangements for intensive care and request the appropriate surgical consultation.
- An infectious disease consultation should be considered in choosing the proper antibiotic coverage for the CST
Laupland KB. Vascular and parameningeal infections of the head and neck. Infect Dis Clin North Am. Jun 2007;21(2):577-90, viii. [Medline].
Seow VK, Chong CF, Wang TL, Lin CM, Lin IY. Cavernous sinus thrombophlebitis masquerading as ischaemic stroke: a catastrophic pitfall in any emergency department. Emerg Med J. Jun 2007;24(6):440. [Medline].
Duong DK, Leo MM, Mitchell EL. Neuro-ophthalmology. Emerg Med Clin North Am. Feb 2008;26(1):137-80, vii. [Medline].
Misra UK, Kalita J, Bansal V. D-dimer is useful in the diagnosis of cortical venous sinus thrombosis. Neurol India. Jan-Feb 2009;57(1):50-4. [Medline].
Coutinho J, de Bruijn SF, Deveber G, Stam J. Anticoagulation for cerebral venous sinus thrombosis. Cochrane Database Syst Rev. Aug 10 2011;CD002005. [Medline].
Naesens R, Ronsyn M, Druwé P, Denis O, Ieven M, Jeurissen A. Central nervous system invasion by community-acquired meticillin-resistant Staphylococcus aureus. J Med Microbiol. Sep 2009;58:1247-51. [Medline].
Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to sinusitis: are anticoagulants indicated? A review of the literature. J Laryngol Otol. Sep 2002;116(9):667-76. [Medline].
Canhao P, Ferro JM, Lindgren AG. Causes and predictors of death in cerebral venous thrombosis. Stroke. Aug 2005;36(8):1720-5. [Medline].
Cannon ML, Antonio BL, McCloskey JJ, et al. Cavernous sinus thrombosis complicating sinusitis. Pediatr Crit Care Med. Jan 2004;5(1):86-8. [Medline].
DiNubile MJ. Septic thrombosis of the cavernous sinuses. Arch Neurol. May 1988;45(5):567-72. [Medline].
Ferro JM, Canhao P, Bousser MG. Cerebral vein and dural sinus thrombosis in elderly patients. Stroke. Sep 2005;36(9):1927-32. [Medline].
Goodwin WJ. Orbital complications of ethmoiditis. Otolaryngol Clin North Am. Feb 1985;18(1):139-47. [Medline].
Heckmann JG, Tomandl B. Cavernous sinus thrombosis. Lancet. Dec 13 2003;362(9400):1958. [Medline].
Karlin RJ, Robinson WA. Septic cavernous sinus thrombosis. Ann Emerg Med. Jun 1984;13(6):449-55. [Medline].
Lessner A, Stern GA. Preseptal and orbital cellulitis. Infect Dis Clin North Am. Dec 1992;6(4):933-52. [Medline].
Levine SR, Twyman RE, Gilman S. The role of anticoagulation in cavernous sinus thrombosis. Neurology. Apr 1988;38(4):517-22. [Medline].
Peters KS. Secondary headache and head pain emergencies. Prim Care. Jun 2004;31(2):381-93, vii. [Medline].
Schnipper D, Spiegel JH. Management of intracranial complications of sinus surgery. Otolaryngol Clin North Am. Apr 2004;37(2):453-72, ix. [Medline].
Southwick FS, Richardson EP, Swartz MN. Septic thrombosis of the dural venous sinuses. Medicine (Baltimore). Mar 1986;65(2):82-106. [Medline].
Watkins LM, Pasternack MS, Banks M. Bilateral cavernous sinus thromboses and intraorbital abscesses secondary to Streptococcus milleri. Ophthalmology. Mar 2003;110(3):569-74. [Medline].
Yanofsky NN. The acute painful eye. Emerg Med Clin North Am. Feb 1988;6(1):21-42. [Medline].
Zimmer J, Bhatt J, et al. Is it all in his head?. The Internet Journal of Pediatrics and Neonatology. 2006;6.

