Cerebral venous sinus thrombosis medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Pharmacologic therapy is indicated in cerebral venous sinus thrombosis. Medical therapy includes anticoagulants, [[acetazolamide]], and anticonvulsants. Empiric antimicrobial therapy is required and generally includes the combination of [[Metronidazole]], a [[penicillin|penicillinase-resistant penicillin]], and a third generation [[cephalosporin]]. | |||
==Medical Therapy== | ==Medical Therapy== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kalsang Dolma, M.B.B.S.[2]
Overview
Pharmacologic therapy is indicated in cerebral venous sinus thrombosis. Medical therapy includes anticoagulants, acetazolamide, and anticonvulsants. Empiric antimicrobial therapy is required and generally includes the combination of Metronidazole, a penicillinase-resistant penicillin, and a third generation cephalosporin.
Medical Therapy
Pharmacotherapy
Anticoagulants
Various studies have investigated the use of anticoagulation (suppression of blood clot formation) in cerebral venous sinus thrombosis. Before these trials, there was a concern that small areas of hemorrhage would bleed further as a result of treatment. The European Federation of Neurological Societies (EFNS) recommends heparin or low molecular weight heparin in the initial treatment, followed by warfarin, provided there are no other bleeding risks that would make these treatments unsuitable. The duration of warfarin treatment depends on the circumstances and underlying causes of the condition. If the thrombosis developed under temporary circumstances (e.g. pregnancy), three months are regarded as sufficient. If the condition was unprovoked but there are no clear causes or a "mild" form of thrombophilia, 6 to 12 months is advised. If there is a severe underlying thrombosis disorder, warfarin treatment may need to continue indefinitely.
Thrombolysis
Removal of the blood clot with "clot buster" medication has been described, either systemically by injection into a vein or directly into the clot during angiography. The 2006 EFNS guideline recommends that thrombolysis is only used in patients who deteriorate despite adequate treatment, and other causes of deterioration have been eliminated. It is unclear which drug and which mode of administration is the most effective. Bleeding into the brain and in other sites of the body is a major concern in the use of thrombolysis.
Acetazolamide
It may be used to decrease raised intracranial pressure.[1]
Anticonvulsants
It may be used prophylactically (i.e. to prevent seizures); these are focal neurological problems (e.g. inability to move a limb) and/or focal changes of the brain tissue on CT or MRI scan.
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)[6]
- 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
- ↑ Einhäupl K, Bousser MG, de Bruijn SF; et al. (2006). "EFNS guideline on the treatment of cerebral venous and sinus thrombosis". Eur. J. Neurol. 13 (6): 553–9. doi:10.1111/j.1468-1331.2006.01398.x. PMID 16796579.
- ↑ 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.