Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected cavernous sinus thrombosis (CST)

1st line – empirical antimicrobial therapy + supportive therapy

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INITIAL
|
suspected cavernous sinus thrombosis (CST)
1st line – 

empirical antimicrobial therapy + supportive therapy

High-dose intravenous antibiotics should be instituted at the earliest suspicion of a diagnosis of CST.[2]

Appropriate selection of empiric antibiotic regimens should be directed at the probable organisms implicated at the primary source of infection.

For empirical antibiotic therapy options, based on expert opinion, may include amoxicillin/clavulanate plus gentamicin, a third-generation cephalosporin, a fluoroquinolone, and the addition of metronidazole if brain abscess or dental or sinus infection is suspected.[6][76]​​​​​[77][78]​​​​​ Consider adding vancomycin or linezolid if methicillin-resistant Staphylococcus aureus infection is suspected.[79]​ Consult your local guidelines or infectious disease consultant for more information as this is a very specialised area with little evidence available to guide treatment decisions.

Rarely, fungal infection from Aspergillus fumigatus or mucormycosis have been implicated in CST.[74][75]​​ Antifungal therapy is required rarely and has been advocated only in cases of biopsy-confirmed invasive fungal infection. However, in at-risk patients, such as patients with immunocompromise or poorly controlled diabetes, empirical antifungal treatment should be considered as fungi may cause devastating neurological complications beyond cerebral venous thrombosis.[80]

As soon as the laboratory has reported sensitivities, empiric antibiotics can be switched to specific antibiotic therapy.

High doses of intravenous antibiotics are required. They also need to be administered over an extended period; for at least 3-4 weeks beyond the time of clinical resolution.[39]​​

Concurrent supportive therapy is necessary alongside antibiotic treatment, and includes resuscitation, oxygen support, and local eye care.

ACUTE

confirmed septic cavernous sinus thrombosis (CST): without haemorrhagic complications

1st line – targeted antimicrobial therapy + supportive therapy

Back
ACUTE
|
confirmed septic cavernous sinus thrombosis (CST): without haemorrhagic complications
1st line – 

targeted antimicrobial therapy + supportive therapy

As soon as the laboratory has reported sensitivities, empiric antibiotics can be switched to specific antibiotic therapy.

High doses of intravenous antibiotics are required. They also need to be administered over an extended period; for at least 3-4 weeks beyond the time of clinical resolution.[39]​​

Rarely, fungal infection from Aspergillus fumigatus or mucormycosis have been implicated in CST.[74][75]​​ Duration of therapy is decided in the light of clinical/radiological improvement and resolution of any immune defect; weeks to months of therapy are typically required. Consult an infectious disease consultant for further guidance on when to taper or stop therapy.[96][97]

Concurrent supportive therapy is necessary alongside antibiotic treatment, and includes resuscitation, oxygen support, and local eye care.[5]

Plus – consider initial anticoagulation

Back
ACUTE
|
confirmed septic cavernous sinus thrombosis (CST): without haemorrhagic complications
Plus – 

consider initial anticoagulation

Treatment recommended for ALL patients in selected patient group

Considerable controversy exists concerning the efficacy of anticoagulation. Evidence concerning effects on mortality and morbidity has been inconsistent.[39]​​

There is a risk of haemorrhage but there is some evidence that it prevents propagation and contributes to re-canalisation of the thrombus.

Anticoagulation is contraindicated in intra-cerebral haemorrhage, sub-arachnoid haemorrhage, and bleeding diathesis. Some also consider it to be dangerous in patients with bilateral CST. Based on limited observation, it may be beneficial after exclusion of haemorrhagic complications by CT scan.[2][13][19]

Intravenous unfractionated heparin has been advocated in the early stages. This can be switched to longer-acting agents, such as warfarin, when the patient's condition has stabilised.[48][83]

Alternative anticoagulants (e.g., argatroban) can be considered in patients with, or at risk of, heparin-induced thrombocytopenia.[98]​ However, there is a lack of reported cases of CST or other forms of dural sinus thrombosis that have been treated with these agents. Consult a consultant for guidance on management of patients with heparin-induced thrombocytopenia.

The required duration of anticoagulation has not been determined.[5][6]

Primary options

heparin: 80 units/kg intravenous bolus initially, followed by a 18 units/kg/hour intravenous infusion titrated to an activated partial thromboplastin time (aPTT) between 1.5 and 2.5

Consider – intravenous corticosteroid

Back
ACUTE
|
confirmed septic cavernous sinus thrombosis (CST): without haemorrhagic complications
Consider – 

intravenous corticosteroid

Additional treatment recommended for SOME patients in selected patient group

The role of corticosteroids is controversial in many cases of CST. They are potentially harmful because of their immunosuppressive effects.

However, corticosteroids are absolutely indicated in cases of pituitary insufficiency. Corticosteroid use may have a critical role in patients with Addisonian crisis secondary to ischaemia or necrosis of the pituitary that complicates CST.[89][90]

Although there would seem to be only empiric support for its anti-inflammatory properties, with real fear of generalised sepsis, the use of corticosteroids may be considered and prove helpful in reducing cranial nerve inflammation and secondary cranial nerve dysfunction and also in decreasing orbital oedema.​[5]​​

There are only a few anecdotal reports documented concerning the use of corticosteroids but their efficacy cannot be proved by these reports because other treatments have been used at the same time.[13][37][91][92]

Primary options

hydrocortisone: 100 mg intravenously every 6 hours

OR

dexamethasone sodium phosphate: 10 mg intravenously every 6 hours

Plus – surgical drainage post-stabilisation

Back
ACUTE
|
confirmed septic cavernous sinus thrombosis (CST): without haemorrhagic complications
Plus – 

surgical drainage post-stabilisation

Treatment recommended for ALL patients in selected patient group

As soon as the patient's condition permits, prompt drainage of the primary site of infection (such as para-nasal sinusitis or dental abscess) or other concurrent closed-space infection is advisable.[7][13]​​[94]​​ Surgical drainage of the cavernous sinus is almost never performed.[1]

In sinogenic CST, surgical drainage of the sinuses for all cases has been advocated.[95]

Different operations have been performed to decompress the sinuses, including trans-septal sphenoidectomy, endoscopic sphenoidectomy and ethmoidectomy, as well as external fronto-ethmoidal-sphenoidectomy.

In cases of otogenic CST, mastoidectomy has been performed with decompression of sigmoid sinus thrombophlebitis.[40]

Plus – switch to warfarin post-stabilisation

Back
ACUTE
|
confirmed septic cavernous sinus thrombosis (CST): without haemorrhagic complications
Plus – 

switch to warfarin post-stabilisation

Treatment recommended for ALL patients in selected patient group

When the patient has been stabilised, initial anticoagulation can be substituted with longer-acting anticoagulation such as warfarin.[48]

Primary options

warfarin: 2-10 mg orally once daily initially, adjust dose according to target INR

More

confirmed septic cavernous sinus thrombosis (CST): with haemorrhagic complications

1st line – targeted antimicrobial therapy + supportive therapy

Back
ACUTE
|
confirmed septic cavernous sinus thrombosis (CST): with haemorrhagic complications
1st line – 

targeted antimicrobial therapy + supportive therapy

As soon as the laboratory has reported sensitivities, empiric antibiotics can be switched to specific antibiotic therapy.

High doses of intravenous antibiotics are required. They also need to be administered over an extended period; for at least 3-4 weeks beyond the time of clinical resolution.[39]​​

Antifungal therapy is required rarely and has been advocated only in cases of biopsy-confirmed invasive fungal infection.

Concurrent supportive therapy is necessary alongside antibiotic treatment, and includes resuscitation, oxygen support, and local eye care.[5]

Consider – intravenous corticosteroid

Back
ACUTE
|
confirmed septic cavernous sinus thrombosis (CST): with haemorrhagic complications
Consider – 

intravenous corticosteroid

Additional treatment recommended for SOME patients in selected patient group

The role of corticosteroids is controversial in many cases of CST. They are potentially harmful because of their immunosuppressive effects.

However, corticosteroids are absolutely indicated in cases of pituitary insufficiency. Corticosteroid use may have a critical role in patients with Addisonian crisis secondary to ischaemia or necrosis of the pituitary that complicates CST.[89][90]

Although there would seem to be only empiric support for its anti-inflammatory properties, with real fear of generalised sepsis, the use of corticosteroids may be considered and prove helpful in reducing cranial nerve inflammation and secondary cranial nerve dysfunction and also in decreasing orbital oedema.​[5]​​

There are only a few anecdotal reports documented concerning the use of corticosteroids but their efficacy cannot be proved by these reports because other treatments have been used at the same time.[13][37][91][92]

Primary options

hydrocortisone: 100 mg intravenously every 6 hours

OR

dexamethasone sodium phosphate: 10 mg intravenously every 6 hours

Plus – surgical drainage post-stabilisation

Back
ACUTE
|
confirmed septic cavernous sinus thrombosis (CST): with haemorrhagic complications
Plus – 

surgical drainage post-stabilisation

Treatment recommended for ALL patients in selected patient group

As soon as the patient's condition permits, prompt drainage of the primary site of infection (such as para-nasal sinusitis or dental abscess) or other concurrent closed-space infection is advisable.​[7][13][94]​​ Surgical drainage of the cavernous sinus is almost never performed.[1]

In sinogenic CST, surgical drainage of the sinuses for all cases has been advocated.[95]

Different operations have been performed to decompress the sinuses, including trans-septal sphenoidectomy, endoscopic sphenoidectomy and ethmoidectomy, as well as external fronto-ethmoidal-sphenoidectomy.

In cases of otogenic CST, mastoidectomy has been performed with decompression of sigmoid sinus thrombophlebitis.[40]

confirmed aseptic cavernous sinus thrombosis (CST): without haemorrhagic complications

1st line – supportive therapy

Back
ACUTE
|
confirmed aseptic cavernous sinus thrombosis (CST): without haemorrhagic complications
1st line – 

supportive therapy

Concurrent supportive therapy is necessary and includes resuscitation, oxygen support, and local eye care.[5]

Plus – initial anticoagulation

Back
ACUTE
|
confirmed aseptic cavernous sinus thrombosis (CST): without haemorrhagic complications
Plus – 

initial anticoagulation

Treatment recommended for ALL patients in selected patient group

Anticoagulation is the standard of care in the management of aseptic CST if there are no haemorrhagic complications.[39]​​

​Intravenous unfractionated heparin has been advocated in the early stages. This can be switched to longer-acting agents, such as warfarin, when the patient's condition has stabilised.[48]

Alternative anticoagulants (e.g., argatroban ) can be considered in patients with, or at risk of, heparin-induced thrombocytopenia.[98]​ However, there is a lack of reported cases of CST or other forms of dural sinus thrombosis that have been treated with these agents. Consult a consultant for guidance on management of patients with heparin-induced thrombocytopenia.

The required duration of anticoagulation has not been determined.

Primary options

heparin: 80 units/kg intravenous bolus initially, followed by a 18 units/kg/hour intravenous infusion titrated to an activated partial thromboplastin time (aPTT) between 1.5 and 2.5

Consider – endovascular therapy

Back
ACUTE
|
confirmed aseptic cavernous sinus thrombosis (CST): without haemorrhagic complications
Consider – 

endovascular therapy

Additional treatment recommended for SOME patients in selected patient group

If a patient is considered suitable for anticoagulation but deteriorates despite this therapy, they may be considered for endovascular treatment.[85][86][87]​ Although endovascular treatment is increasingly being used to treat patients with cerebral venous thrombosis, this treatment is not routinely recommended in all patients.[88]​​ This therapy is usually reserved for progressive, aseptic CST and carries with it the risks of intracranial haemorrhage, stroke, and the inability to re-canalise. It does not preclude corticosteroids.

Consider – intravenous corticosteroid

Back
ACUTE
|
confirmed aseptic cavernous sinus thrombosis (CST): without haemorrhagic complications
Consider – 

intravenous corticosteroid

Additional treatment recommended for SOME patients in selected patient group

The role of corticosteroids is controversial in many cases of CST. They are potentially harmful because of their immunosuppressive effects.

However, corticosteroids are absolutely indicated in cases of pituitary insufficiency. Corticosteroid use may have a critical role in patients with Addisonian crisis secondary to ischaemia or necrosis of the pituitary that complicates CST.[89][90]

Although there would seem to be only empiric support for its anti-inflammatory properties, with real fear of generalised sepsis, the use of corticosteroids may be considered and prove helpful in reducing cranial nerve inflammation and secondary cranial nerve dysfunction and also in decreasing orbital oedema.​[5]​​

There are only a few anecdotal reports documented concerning the use of corticosteroids but their efficacy cannot be proved by these reports because other treatments have been used at the same time.[13][37][91][92]

Primary options

hydrocortisone: 100 mg intravenously every 6 hours

OR

dexamethasone sodium phosphate: 10 mg intravenously every 6 hours

Plus – switch to warfarin post-stabilisation

Back
ACUTE
|
confirmed aseptic cavernous sinus thrombosis (CST): without haemorrhagic complications
Plus – 

switch to warfarin post-stabilisation

Treatment recommended for ALL patients in selected patient group

When the patient has been stabilised, initial anticoagulation can be substituted with longer-acting anticoagulation such as warfarin.[48]

Primary options

warfarin: 2-10 mg orally once daily initially, adjust dose according to target INR

More

confirmed aseptic cavernous sinus thrombosis (CST): with haemorrhagic complications

1st line – supportive therapy

Back
ACUTE
|
confirmed aseptic cavernous sinus thrombosis (CST): with haemorrhagic complications
1st line – 

supportive therapy

Concurrent supportive therapy is necessary and includes resuscitation, oxygen support, and local eye care.[39]

Consider – intravenous corticosteroid

Back
ACUTE
|
confirmed aseptic cavernous sinus thrombosis (CST): with haemorrhagic complications
Consider – 

intravenous corticosteroid

Additional treatment recommended for SOME patients in selected patient group

The role of corticosteroids is controversial in many cases of CST. They are potentially harmful because of their immunosuppressive effects.

However, corticosteroids are absolutely indicated in cases of pituitary insufficiency. Corticosteroid use may have a critical role in patients with Addisonian crisis secondary to ischaemia or necrosis of the pituitary that complicates CST.[89][90]

Although there would seem to be only empiric support for its anti-inflammatory properties, with real fear of generalised sepsis, the use of corticosteroids may be considered and prove helpful in reducing cranial nerve inflammation and secondary cranial nerve dysfunction and also in decreasing orbital oedema.​[5]​​

There are only a few anecdotal reports documented concerning the use of corticosteroids but their efficacy cannot be proved by these reports because other treatments have been used at the same time.[13][37][91][92]

Primary options

hydrocortisone: 100 mg intravenously every 6 hours

OR

dexamethasone sodium phosphate: 10 mg intravenously every 6 hours

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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