Cavernous sinus thrombosis medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
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 (Nafcillin 2 g IV q4h for 3-4 weeks | 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 ([[Nafcillin]] 2 g IV q4h for 3-4 weeks {{or}} [[Oxacillin]] 2 g IV q4h 3-4 weeks) {{and}} ([[Ceftriaxone]] 2 g IV q12h 3-4 weeks {{or}} [[Cefotaxime]] 8–12 g/day IV q4–6h 3-4 weeks) {{and}} [[Metronidazole]] 7.5 mg/kg IV q6h 3-4 weeks. If the risk of [[MRSA]] is high, [[Vancomycin]] 30–45 mg/kg IV q8–12h may be used instead of either nafcillin or oxacillin. | ||
==Medical Therapy== | ==Medical Therapy== | ||
Revision as of 19:19, 6 October 2015
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
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 (Nafcillin 2 g IV q4h for 3-4 weeks OR Oxacillin 2 g IV q4h 3-4 weeks) AND (Ceftriaxone 2 g IV q12h 3-4 weeks OR Cefotaxime 8–12 g/day IV q4–6h 3-4 weeks) AND Metronidazole 7.5 mg/kg IV q6h 3-4 weeks. If the risk of MRSA is high, Vancomycin 30–45 mg/kg IV q8–12h may be used instead of either nafcillin or oxacillin.
Medical Therapy
- Antithrombotics
- Anticoagulation
- Standard treatment at this time, even if moderate intracranial hemorrhage present
- Controversial in the past given risk of associated hemorrhage – one small randomized study with 20 patients in each arm showed a significant benefit making anticoagulation standard of care.
- Thrombolysis – with agents like urokinase, TPA – generally given via microcatheters inserted for local infusion
- Initial infusion sometimes followed by continuous infusion for a day or more until clot clears.
- Many case reports of success, but not standard treatment at this time.
- A study of 9 patients in Korea showed successful thrombolysis in all patients
- Risk of hemorrhage
- The literature suggests that it is mostly used now in severe cases with stupor, coma, rapidly progressing course, or severely raised ICP, and only in centers experienced in the methodology. Its role may expand with more experience.
- Surgical thrombectomy – not generally performed anymore
- Antieleptics – as indicated
- Antibiotics – if infectious precipitant
- Intracranial pressure manipulation
- Medical: mannitol, steroids, acetazolamide, repeat LPs
- Shunt
Antimicrobial Regimen
- 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
-
- 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
References
- ↑ Saposnik, Gustavo; Barinagarrementeria, Fernando; Brown, Robert D.; Bushnell, Cheryl D.; Cucchiara, Brett; Cushman, Mary; deVeber, Gabrielle; Ferro, Jose M.; Tsai, Fong Y.; American Heart Association Stroke Council and the Council on Epidemiology and Prevention (2011-04). "Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association". Stroke; a Journal of Cerebral Circulation. 42 (4): 1158–1192. doi:10.1161/STR.0b013e31820a8364. ISSN 1524-4628. PMID 21293023. Check date values in:
|date=(help) - ↑ Ebright, J. R.; Pace, M. T.; Niazi, A. F. (2001-12-10). "Septic thrombosis of the cavernous sinuses". Archives of Internal Medicine. 161 (22): 2671–2676. ISSN 0003-9926. PMID 11732931.
- ↑ Singh, B. (1993-09). "The management of lateral sinus thrombosis". The Journal of Laryngology and Otology. 107 (9): 803–808. ISSN 0022-2151. PMID 8228594. Check date values in:
|date=(help) - ↑ Southwick, F. S.; Richardson, E. P.; Swartz, M. N. (1986-03). "Septic thrombosis of the dural venous sinuses". Medicine. 65 (2): 82–106. ISSN 0025-7974. PMID 3512953. Check date values in:
|date=(help) - ↑ Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.