eMedicine Specialties > Emergency Medicine > Neurology
Cavernous Sinus Thrombosis: Treatment & Medication
Updated: Jul 18, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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. 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.
- 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.
Medication
Antibiotic therapy ideally is started after appropriate cultures but should not be delayed if difficulties exist in obtaining specimens. Antibiotics selected should be broad-spectrum, particularly active against S aureus, and capable of achieving high levels in the cerebrospinal fluid. With the recent increased prevalence of community-acquired MRSA, the emergency physician should consider additional coverage with intravenous antibiotics, such as vancomycin, if MRSA infection is suspected.
Antibiotic, Miscellaneous
Empiric broad-spectrum coverage for gram-positive, gram-negative, and anaerobic organisms is necessary. Therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
In cases of suspected MRSA infection, vancomycin should be added for additional coverage.
Oxacillin (Bactocill)
A bactericidal antibiotic that inhibits cell wall synthesis. Used in treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when staphylococcal infection is suspected.
Adult
2 g IV q4h
Pediatric
50-100 mg/kg/d PO divided q6h
150-200 mg/kg/d IV/IM divided q6h; not to exceed 12 g/d
Decreases effects of contraceptives and tetracycline; disulfiram and probenecid may increase levels; large IV doses may increase effects of anticoagulants
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Ceftriaxone (Rocephin)
Alternate antimicrobial choice. Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms than earlier generation cephalosporins. By binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.
Adult
2 g IV q12h
Pediatric
75 mg/kg/d IV divided bid
Probenecid may increase levels; ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin
Metronidazole (Flagyl)
Additional anaerobic coverage. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Usually employed in combination with other antimicrobial agents (except when used for Clostridium difficile enterocolitis, in which monotherapy appropriate).
Adult
500 mg IV q6h
Pediatric
Not established
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity, first trimester of pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Chloramphenicol (Chloromycetin)
Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult
1.5 g IV q6h
Pediatric
50-75 mg/kg/d PO/IV divided q6h
Barbiturates may decrease serum levels, while chloramphenicol may increase barbiturate levels, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; hydantoin may increase or decrease chloramphenicol levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only for indicated infections, or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline blood studies and repeat approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Vancomycin
Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin allergic patients undergoing gastrointestinal or genitourinary procedures.
Adult
1 g or 15 mg/kg IV q12h
Pediatric
30-40 mg/kg/d IV in 2 doses
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
Anticoagulants
Unfractionated IV heparin and fractionated low-molecular-weight SC heparins are the 2 options in anticoagulation therapy.
Heparin
Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse thrombus but able to inhibit further thrombogenesis. Prevents reaccumulation of clot after spontaneous fibrinolysis. Various dosing nomograms available.
Adult
80 U/kg IV bolus; then 18 U/kg/h IV infusion; titrate to desired aPTT
Pediatric
Administer as in adults
Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, aspirin, dextran, dipyridamole, and hydroxychloroquine may increase toxicity
Documented hypersensitivity; subacute bacterial endocarditis; intracerebral hemorrhage, bleeding diathesis, or other active bleeding; history of heparin-induced thrombocytopenia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In neonates, preservative-Free heparin is recommended to avoid possible toxicity (gasping syndrome) by benzyl alcohol, which is used as preservative; caution in severe hypotension and shock; monitor for bleeding in peptic ulcer disease, menstruation, increased capillary permeability, and when giving IM injections
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli. When the course of CST leads to pituitary insufficiency, corticosteroids definitely are indicated to prevent adrenal crisis.
Hydrocortisone (Solu-Cortef, Westcort)
DOC due to its mineralocorticoid activity and glucocorticoid effects. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Useful in management of inflammation caused by an immune response.
Adult
100 mg IV q6h
Pediatric
Infants and young children: 1-2 mg/kg IV as bolus followed by 25-150 mg/d divided q6-8h
Clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis
More on Cavernous Sinus Thrombosis |
| Overview: Cavernous Sinus Thrombosis |
| Differential Diagnoses & Workup: Cavernous Sinus Thrombosis |
 Treatment & Medication: Cavernous Sinus Thrombosis |
| Follow-up: Cavernous Sinus Thrombosis |
| Multimedia: Cavernous Sinus Thrombosis |
| References |
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References
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].
Duong DK, Leo MM, Mitchell EL. Neuro-ophthalmology. Emerg Med Clin North Am. Feb 2008;26(1):137-80, vii. [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.
Further Reading
Keywords
cavernous sinus thrombosis, CST, thrombosis of the cavernous intracranial sinus, cavernous sinus syndrome, cavernous sinus, cavernous sinuses, parasellar lesions, tumors, carotid artery aneurysms, carotid-cavernous fistulas, C-C fistulas, cavernous sinus thrombosis
