Cerebral Venous Thrombosis Outcomes in Immunocompromised Patients with Sphenoid Sinusitis

Introduction Cerebral venous thrombosis (CVT) is a rare but serious condition affecting the neurovascular system. When septic, it presents heightened diagnostic and treatment challenges, particularly in the use of anticoagulation. We report a case of septic CVT secondary to skull‐base infection in an immunocompromised patient on combination immunosuppressive therapy for rheumatoid arthritis. This report highlights the ongoing controversy regarding anticoagulation in septic CVT and discusses how current guidelines and selective data influenced clinical management decisions. Materials/Methods This was a descriptive single case report. We reviewed clinical presentation, imaging, decision‐making regarding anticoagulation, and outcome. We synthesized these elements with existing data and guideline recommendations. Results/Case An 82‐year‐old woman with rheumatoid arthritis on multiple immunosuppressive therapies presented with headache, diplopia, and cranial nerve involvement. Imaging confirmed sphenoid sinusitis with skull‐base osteomyelitis and thrombosis of the sigmoid sinus and internal jugular vein, with possible straight sinus extension. Sphenoid debridement and culture‐directed antibiotics were administered. Anticoagulation with heparin was initiated but intermittently paused due to epistaxis. Sphenopalatine artery ligation stabilized the bleeding risk, enabling transition to apixaban. The patient showed marked neurological improvement without hemorrhage and was discharged on long‐term anticoagulation for newly diagnosed atrial fibrillation, with concurrent infection resolution and no bleeding events. Conclusion Septic CVT is a high‐stakes complication of adjacent infectious processes. Despite theoretical risks, anticoagulation, when appropriately timed with infection control, is considered safe and effective. The theoretical advantage of anticoagulation therapy is prevention of the propagation of thrombus, as well as possible inhibition of platelet function and anti‐inflammatory effect through various mechanisms. Most evidence addresses aseptic CVT. A multicenter retrospective study found direct oral anticoagulants (DOACs), predominantly apixaban, provided similar outcomes and a favorable safety profile compared with warfarin, consistent with RESPECT‐CVT. A separate cohort showed DOACs reduced CVT recurrence and ICH risk with comparable all‐cause mortality. In septic CVT specifically, pediatric and adult cohorts demonstrate that anticoagulation can be used safely without increased hemorrhagic complications. Current AHA/ASA guidelines recommend initiating parenteral anticoagulation (UFH or LMWH) followed by oral therapy, with 3‐6 months of treatment reasonable for provoked CVT, though septic CVT data remain sparse. Our case supports guideline‐aligned, individualized, multidisciplinary management and highlights the need for further research on optimal septic CVT treatment strategies.