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Cavernous Sinus Thrombosis Treatment & Management

  • Author: Rahul Sharma, MD, MBA, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: May 10, 2016
 

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 two 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.[9] Therefore, anticoagulation with heparin should be considered since the goal is to prevent further thrombosis and to reduce the incidence of septic emboli. One review suggests that low-molecular weight heparin (LMWH) is superior to unfractionated heparin (UFH).[10] 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.

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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.

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Contributor Information and Disclosures
Author

Rahul Sharma, MD, MBA, FACEP Medical Director and Associate Chief of Service, NYU Langone Medical Center, Tisch Hospital Emergency Department; Assistant Professor of Emergency Medicine, New York University School of Medicine

Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Association for Physician Leadership, Phi Beta Kappa, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Edward Bessman, MD, MBA Chairman and Clinical Director, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

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Anatomy of cross section of cavernous sinus showing close proximity to cranial nerves and sphenoid sinus.
 
 
 
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