Alexander E. Merkler, MD

Head and Neck Infections are not uncommonly associated with central venous thrombosis (CVT). Previous studies claimed that in as many as 60% of cases of CVT, there is an associated ENT or CNS infection, although more recent publications state that the rates of associated infections are much less, likely due to improved antibiotic treatment. Despite the presence of intracerebral hemorrhage, CVT is typically treated with anticoagulation. On the other hand, there is insufficient evidence to support treatment with anticoagulation for CVT due to or associated with a concurrent head or neck infection.

In the current study, Dr. Zuurbier et al. assess the differences between CVT patients with and without concurrent head or neck infection. In addition, the authors assess the use and effect of anticoagulation in patients with CVT and concurrent infection. This study data was collected as part of the prospectively gathered International Study on Cerebral Venous and Dural Venous Thrombosis (ISCVT) which included 624 adults with CVT.

Out of the 624 patients with CVT, 77 patients had an infection. Twenty had an infection outside of the head or neck and were excluded. Thus, out of the 600 patients that remained, 57 patients had a head or neck infection, out of which an ENT infection (mastoiditis) was the most common. Thirteen (22.8%) had a CNS infection. As compared to patients without an infection, cavernous sinus thrombosis was more common in patients with an infection (7.7 versus 0.7%). In addition, an ICH at baseline was less common in patients with an infection (21.1 versus 41.6%). The proportion of patients who received therapeutic anticoagulation was the same in patients with or without an infection (82.% versus 83.7%). Of the patients with an infection, there were no significant baseline differences between those who received anticoagulation and those who did not.

Neurological outcomes (as defined by mRS upon last follow-up) were similar between patients with or without infections; 15.8 versus 13.7% of patients were dead or dependent (mRS>2) at last follow-up. In addition, mortality was similar between patients with and without infection (5.3% versus 3.3%). A new ICH was more common in patients with an infection than without an associated infection (12.3 versus 5.3%) and although not statistically significant due to low numbers of patients, clinical worsening was more frequent in patients with an infection who were treated with anticoagulation (31.9 versus 10%). On the other hand, despite clinical worsening, clinical outcomes at last follow-up and mortality were very similar in patients with an infection treated or not treated with anticoagulation.

One of the most surprising findings of this study was the fact that clinicians were not deterred in prescribing full dose anticoagulation in patients with active ENT/CNS infection. Although overall mortality and neurological outcomes were similar in patients with CVT and concurrent infections treated or not treated with anticoagulation, only 10 patients with CVT and concurrent infection were not treated with anticoagulation and therefore it is hard to attest to the efficacy/safety of anticoagulation in this particularly challenging subgroup of patients.