Cavernous sinus thrombosis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Cavernous sinus thrombosis is a medical emergency. Pharmacologic medical therapies for cavernous sinus thrombosis include antithombotic agents, antibiotics, and drugs such as mannitol, steroids and acetazolamide to decrease the intracranial pressure. Empiric antimicrobial therapy for septic thrombosis of cavernous or dural venous sinus includes metronidazole plus either nafcillin or oxacillin with either ceftriaxone or cefotaxime. Generally, the preferred empiric regimen for the treatment of cavernous sinus thrombosis is (Vancomycin 30–45 mg/kg IV q8–12h for 3-4 weeks OR Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks. If the risk of MRSA is high, vancomycin should be used instead of either nafcillin or oxacillin. Other pharmacologic therapies include antithrombotic agents (usually LMWH) to prevent clot formation, steroid therapy (e.g. Dexamethasone 10 mg q6h) for symptomatic relief, and mannitol and acetazolamide to reduce the elevated intracranial pressure. Antiepileptic therapy should be administered only if patients develop seizures.

• Antithrombotics to prevent clot formation

Note: Antithrombotics may be contraindicated. Cerebral infarction and intracranial hemorrhage must first be ruled out by head CT scan prior to administration of antithrombotic agents

• Anticoagulation (usually heparin / LMWH)
• Thrombolysis may be performed – with agents like urokinase, TPA – generally given via microcatheters inserted for local infusion

• Antieleptics – as indicated
• Antibiotics – if infectious precipitant
• Reduction of intracranial pressure

• Medical: mannitol, steroids, acetazolamide, repeat LPs
• Shunt

• Cavernous sinus thrombosis is considered a medical emergency.
• Duration of therapy is usually a total of 3-4 weeks. More prolonged administration of antimicrobial therapy (total of 6-8 weeks) may be indicated among patients who are suspected to have developed complications (e.g. suppurative intracranial disease).
• ENT surgery must be consulted to evaluate the need of surgical drainage (e.g. sphenoidotomy if sphenoid sinus infection is the primary cause).
• Septic thrombosis of cavernous or dural venous sinus

• 1. Empiric antimicrobial therapy^[1][2][3][4]

• Preferred regimen: (Vancomycin 30–45 mg/kg IV q8–12h for 3-4 weeks OR Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h for 3-4 weeks) AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h 3-4 weeks

Note (1): If risk of MRSA is high, Vancomycin should be administered instead of either nafcillin or oxacillin

Note (2): The optimal duration of therapy remains unclear

• 2. Specific anatomic considerations

• 2.1 Cavernous sinus

• Preferred regimen: Vancomycin 30–45 mg/kg IV q8–12h for 3-4 weeks AND (Ceftriaxone 2 g IV q12h for 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h for 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h for 3-4 weeks

Note: Daptomycin 8–12 mg/kg IV q24h OR Linezolid 600 mg IV q12h could be considered for patients unable to tolerate vancomycin

• 2.2 Lateral sinus

• Preferred regimen: Cefepime 2 g IV q8h for 3-4 weeks AND Metronidazole 500 mg IV q8h for 3-4 weeks AND Vancomycin 15-20 IV mg/kg for 3-4 weeks
• Alternative regimen: Meropenem 1-2 g IV q8h 3-4 weeks AND Linezolid 600 mg IV q12h 3-4 weeks

• 2.3 Superior sagittal sinus

• Preferred regimen: Ceftriaxone 2 g IV q12h for 3-4 weeks AND Vancomycin 15–20 mg/kg for 3-4 weeks AND Dexamethasone 10 mg IV q6h continued until symptomatic improvement and tailed gradually over several weeks
• Alternative regimen: Meropenem 1–2 g IV q8h for 3-4 weeks AND Vancomycin 15–20 mg/kg for 3-4 weeks AND Dexamethasone 10 mg IV q6h continued until symptomatic improvement and tailed gradually over several weeks

• 3. Pathogen-directed antimicrobial therapy

• Staphylococcus aureus, methicillin-resistant (MRSA)^[5]

• Preferred regimen: Vancomycin 15–20 mg/kg/dose IV q8–12h for 4–6 weeks
• Alternative regimen: Linezolid 600 mg PO/IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
• Pediatric dose: Vancomycin 15 mg/kg/dose IV q6h 4–6 weeks OR Linezolid 10 mg/kg/dose PO/IV q8h 4–6 weeks
• Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible
• Note (2): Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to vancomycin