Carotid-cavernous fistula: A potential treatable cause of bilateral abducens palsy and conjunctival hyperemia.

OBJECTIVE: Carotid cavernous fistulas (CCFs) represent uncommon and anomalous communications between the carotid artery and the cavernous sinus. MATERIALS AND METHODS: Case report RESULTS: We present the clinical details and successful management of a previously healthy 44-year-old patient who presented with one-month worsening headache, bilateral abducens palsy and conjunctival injection. Imaging modalities including magnetic resonance imaging (MRI) with contrast and digital subtraction angiography (DSA) facilitated the diagnosis of CCF. The patient underwent endovascular coiling of the CCF, leading to neurological recovery and symptom remission. CONCLUSION: This case highlights the importance of promptly CCF diagnosis in patients with multiple cranial nerve palsies and conjunctival hyperemia. Moreover, it emphasizes the efficacy of endovascular coiling in achieving symptom remission.

Post-traumatic carotid-cavernous fistula.

A 28-year-old woman who suffered a head injury 2 months before presented with a history of progressive right eye proptosis, ophthalmoplegia, and conjunctival injection. The radiological workup with a magnetic resonance imaging of the brain and cerebral angiography revealed a direct, high-flow, right post-traumatic carotid-cavernous fistula. An endovascular procedure was performed, and the carotid-cavernous fistula was successfully occluded with a progressive resolution of the complained symptoms.

Neovascular glaucoma with combined retinal vascular occlusion in carotid cavernous fistula.

Carotid cavernous fistulas (CCFs) can present with varied ophthalmic manifestations. The most important vision-threatening complications of CCF include glaucoma and retinal vascular occlusions. We report a case of a man in his early 30s who developed a post-traumatic direct CCF. The patient denied undergoing embolisation therapy. This resulted in aggravation of his condition with onset of combined retinal venous and artery occlusion leading to neovascular glaucoma and severe vision loss. He was treated with medical management followed by diode laser photocoagulation to control intraocular pressure. Diagnostic cerebral angiography done 3 months later showed complete closure of the fistula; hence, no further intervention was advocated. Combined vascular occlusion is a rare vision-threatening occurrence in cases of CCF. Timely intervention with closure of the fistula can prevent the development of vision-threatening complications.

Endovascular Treatment of a Traumatic Carotid Cavernous Fistula Concomitant with Intracranial Pseudoaneurysm by Flow Diverter, 2-Dimensional Operative Video.

Traumatic carotid cavernous fistulas (TCCFs) and traumatic intracranial pseudoaneurysms are uncommon vascular anomalies associated with head trauma.1,2 Detachable balloons, covered stents, or liquid embolic agents can be used to treat TCCFs in some conditions.3,4 TCCF concomitant with pseudoaneurysm is an extremely rare occurrence in the literature.5,6 In Video 1, we present a unique case of a TCCF concomitant with a giant pseudoaneurysm of the posterior communicating segment of the left internal carotid artery in a young patient. Both lesions were successfully managed with an endovascular treatment using a Tubridge flow diverter (MicroPort Medical Company, Shanghai, China), coils, and Onyx 18 (Medtronic, Bridgeton, Missouri, USA). No neurologic complications occurred due to the procedures. Six-month follow-up angiography illustrated complete resolution of fistula and pseudoaneurysm. This video shows a new treatment method for TCCF concomitant with a pseudoaneurysm. The patient consented to the procedure.

Incomplete Third Nerve Palsy Due to a Carotid-Cavernous Fistula.

INTRODUCTION: The approach to oculomotor nerve palsies involves the exclusion of compressive, infective, inflammatory, or ischemic lesions. Dural arteriovenous fistulae, including carotid-cavernous fistulae (CCF), are known causes of third nerve palsy. However, diagnosis can sometimes be delayed or missed due to the various clinical presentations. CCF remains a rare but treatable cause of third nerve palsy. CASE REPORT: A 63-year-old Chinese female presented to our unit with gradual onset horizontal diplopia. Clinical examination revealed a partial left oculomotor nerve palsy without congestive eye symptoms. A cerebral angiogram revealed a left indirect CCF supplied by the inferolateral trunk of the left internal carotid artery. She underwent successful transvenous embolization. She improved postprocedure and was discharged well on day 10 of her admission. She was reviewed at 2 months follow-up and had recovered completely. CONCLUSION: Our case is a classic description of a CCF with posterior drainage into the inferior petrosal sinus. We hope this case and a review of the literature can serve as a reminder to clinicians of the varied presentations of CCF. We believe this case adds value to the clinicians in contributing to their diagnostic process and to our interventional colleagues in highlighting a case with a successful postembolization outcome.

RARE PRESENTATION OF BILATERAL CAROTID-CAVERNOUS FISTULA AS SUPRACHOROIDAL HEMORRHAGE DURING CATARACT SURGERY.

OBJECTIVE: To report a rare case of suprachoroidal hemorrhage during phacoemulsification in a patient with bilateral carotid-cavernous fistula. METHOD: Case report. RESULT: A 76-year-old woman with underlying hypertension presented left eye poor vision due to an underlying dense cataract. Her initial preoperative assessment was uneventful, and she underwent phacoemulsification. During epinucleus removal, there was sudden, unexpected anterior chamber shallowing, resulting in posterior capsule rupture. While the surgeon extended the wound to facilitate epinucleus removal, there was a further decrease of red reflex, followed by hardening of the globe, indicating a suprachoroidal hemorrhage. The corneal wound was opposed swiftly without an intraocular lens. Further evaluation after that revealed the patient had a chronic headache for several years, and ocular examination showed bilateral esophoria. A computed tomography demonstrated features suggestive of bilateral carotid-cavernous fistula, which was confirmed with computed tomography angiography later. CONCLUSION: Patients with carotid-cavernous fistula have elevated episcleral venous pressure and vortex venous pressure. Sudden decompression of the globe in these patients predisposes them to higher suprachoroidal hemorrhage risk, although this condition is generally rare in phacoemulsification.

Septic cavernous sinus thrombosis after minor head trauma: A case report.

RATIONALE: Septic cavernous sinus thrombosis (SCST) is a rare but life-threatening condition that commonly arises from infections, including paranasal sinusitis, otitis media, and skin infection. Meanwhile, head trauma as a predisposing factor of SCST has been scarcely reported. We report a case of SCST complicated by meningitis after minor head trauma, even in the absence of identifiable fractures. PATIENT CONCERNS AND DIAGNOSIS: A 77-year-old female presented with diplopia combined with ocular pain and headache lasting a week. She had a recent blunt head trauma 2 weeks before the diplopia onset. The trauma was not accompanied by identifiable skull fractures, bleeding, or loss of consciousness. Neurological examination revealed incomplete ptosis, eyelid swelling, and medial and vertical gaze limitations of both eyes. Gadolinium-enhanced brain magnetic resonance imaging demonstrated multifocal thrombotic filling defects, including those of the cavernous sinus, sinusitis involving the sphenoid and ethmoid sinuses, and otomastoiditis. The cerebrospinal fluid assay result was compatible with bacterial meningitis. A tentative diagnosis of SCST complicated by bacterial meningitis and multifocal cerebral venous thrombosis was made based on clinical, laboratory, and neuroradiologic findings. INTERVENTION: Intravenous triple antibiotic therapy (vancomycin, ceftriaxone, and ampicillin) for 2 weeks combined with methylprednisolone (1 g/d for 5 days) was administered. Despite the initial treatment, carotid-cavernous fistula was newly developed during hospitalization. Therefore, coil embolization was performed successfully for the treatment of carotid-cavernous fistula. OUTCOMES: The symptoms of the patient including diplopia gradually improved during the 8-month follow-up period. LESSONS: Minor head trauma is a rare but possible cause of SCST. Early recognition and prompt treatment are essential for improving outcomes. Moreover, close observation is warranted, even if apparent serious complications were absent during initial evaluations in minor head trauma.

PARACENTRAL ACUTE MIDDLE MACULOPATHY IN A CASE OF HIGH-FLOW DIRECT CAROTID CAVERNOUS FISTULA.

PURPOSE: To report a case of paracentral acute middle maculopathy in a patient with high-flow carotid cavernous fistula. METHODS: A case report of a 53-year-old male patient who sustained an iatrogenic high-flow carotid cavernous fistula and secondary paracentral acute middle maculopathy. RESULTS: At review 1-week postembolization of the carotid cavernous fistula, there was no significant improvement in visual acuity, tests of optic nerve function, external ophthalmoplegia, and ptosis. Spectral domain optical coherence tomography was performed, which revealed hyperreflectivity of the parafoveal plexiform layers of the right eye with ill-defined margins straddling the inner nuclear layer. CONCLUSION: We suggest that spectral domain optical coherence tomography be performed in cases of high-flow direct carotid cavernous fistula where the best-corrected visual acuity is reduced out of keeping with other ophthalmic manifestations.

Transvenous Onyx Embolization of a Type D Carotid-Cavernous-Fistula: Operative Video.

Carotid-cavernous fistulas (CCFs) are acquired pathologic shunts between the carotid circulation and the cavernous sinus that result in venous congestion.1 They often present with ocular symptoms, such as chemosis, proptosis, and blurry vision. Cranial nerve deficits and increased intraocular pressure are often seen on the neuro-ophthalmologic examination.2 If left untreated, they can lead to cortical venous reflux and intracranial hemorrhage. A cerebral angiogram is the gold standard to diagnose these lesions. The hallmark of dural CCF is opacification of venous structures in the arterial phase of the angiogram. Dependent on carotid branches contributing to the fistula, 4 types are classically defined by Barrow et al.3 When the fistula is indirect (types B-D), the goal of treatment is obliteration via the transvenous route.4 We present the case of a patient who had chemosis and proptosis of the left eye with imaging findings concerning for dural CCF (Video 1). An informed consent was obtained and the patient underwent a cerebral angiogram and treatment of the CCF. In the operative video, we showcase the treatment of a type D CCF using transvenous embolization with Onyx (Covidien, Irvine, CA) and achieve angiographic cure of the fistula. We were able to use Onyx for embolization since the superselective injection did not show cortical venous drainage. This is important as obliteration of cortical veins with liquid embolisate could cause venous infarcts. To our knowledge, this is the first video article that illustrates the endovascular embolization of a CCF and highlights the angiographic findings pre- and post-embolization.

Sphenoid sinus pseudoaneurysm with carotid cavernous fistula presenting with delayed subarachnoid hemorrhage: A case report.

RATIONALE: Sphenoid sinus pseudoaneurysm arising from the cavernous segment of the internal carotid artery (ICA) caused by traumatic vessel injury is rare, and rarer is a concomitant carotid-cavernous fistula (CCF). In particular, delayed subarachnoid hemorrhage (SAH) due to pseudoaneurysm rupture has not been reported to-date in literature. Here, we report a case of sphenoid sinus pseudoaneurysm with CCF presenting with delayed SAH. PATIENT CONCERNS: A 73-year-old man presented with traumatic brain injury due to motorcycle accident. DIAGNOSES: Twenty-four days after admission, the patient's neurological status suddenly deteriorated. Brain computed tomography (CT) showed acute SAH along interhemispheric cisterns and suprasellar intracerebral hematoma. Brain CT angiography and digital subtraction angiography revealed giant sphenoid sinus pseudoaneurysm with CCF and the daughter sac of the pseudoaneurysm extended to the intracranial part via fracture in the superior wall of the sphenoid sinus. INTERVENTIONS: As the sphenoid sinus pseudoaneurysm and CCF shared one rupture point, endovascular treatment with intraarterial approach using coil and liquid embolic material by balloon assisted technique was performed simultaneously. OUTCOMES: The origin of the pseudoaneurysmal sac and CCF was sufficiently blocked after injection of liquid embolic material and the lesions completely resolved immediately after endovascular treatment. LESSONS: Sphenoid sinus pseudoaneurysm and CCF rarely occur following head trauma through a series of processes involving fracture of the lateral wall of the sphenoid sinus and ICA cavernous segment injury. Sphenoid sinus pseudoaneurysm may present as SAH through intracranial rupture with concomitant superior wall fracture of the sphenoid sinus. Therefore, early diagnosis using CT or magnetic resonance angiography and appropriate treatment through understanding the disease mechanism is necessary.

Clinical improvement in indirect carotid cavernous fistulas treated endovascularly: A patient based review.

Patients with indirect carotid cavernous fistulas (CCF) were reviewed to emphasize the importance of diagnosing patients even with trivial findings and to raise awareness. Eighteen patients diagnosed as CCF were included. Neuro-ophthalmological findings before and after treatment, diagnostic investigations, treatment, clinical course was noted. Twelve patients were female (67%), 6 were males (33%) and the mean age at presentation was 54 years (range: 29-70 years). Conjunctival hyperemia was present in all patients. Seventeen (94%) patients had proptosis and diplopia, nine (50%) had orbital pain and/or headache, four (22%) had blurred vision, one (5.5%) had ptosis. On examination, 17 patients (94%) had restricted eye movements, four (22%) had low visual acuity and five patients had (28%) increased intraocular pressure (IOP). One patient had been diagnosed as myasthenia gravis and two as thyroid orbitopathy and had been on treatment accordingly before CCF was diagnosed. In two patients, bilateral findings were present despite unilateral CCF on angiography. Barrow Type B fistula was found in 7 (38%), Barrow Type D in 11 (62%) patients. In three bilateral CCF was detected. All were treated by endovascular intervention. Residual deficits at the sixth month control were, eye movement deficits in seven (39%), decrease in visual acuity in one (5.5%) and elevated IOP in one (5.5%) patient. Indirect CCF patients generally present with mild symptoms and the diagnosis may be overlooked. Mild progressive ophthalmoparesis with conjunctival hyperemia must be warning. Though rare bilateral CCF can be detected as well as unilateral CCF with bilateral findings.

Delayed-Onset Cranial Nerve Palsy After Transvenous Embolization of Indirect Carotid Cavernous Fistulas.

BACKGROUND: Carotid cavernous fistulas (CCF) often present with diplopia secondary to cranial nerve palsy (CNP). Immediate development of postoperative CNP has been described in the literature. This study described delayed-onset of CNP after complete and reconfirmed obliteration of the CCF and resolution of initial CNP. METHODS: A retrospective analysis was performed on patients with indirect CCF between 1987 and 2006 at 4 academic endovascular centers. Details of the endovascular procedures, embolic agents used, and complications were studied. Partial or complete obliteration was determined. Immediate and delayed cranial nerve palsies were independently assessed. RESULTS: A total of 267 patients with symptomatic indirect CCF underwent transvenous endovascular treatment. Four patients (1.5%) developed delayed abducens nerve (VI) palsy after complete resolution of presenting symptoms after embolization. Delayed presentation ranged between 3 and 13 months after complete resolution of initial double vision and cranial nerve palsies. Transvenous coil embolization through the inferior petrosal sinus was performed in all 4 affected patients. All had follow-up angiography confirming durable closure of their CCF. MRI did not show new mass lesions or abnormal soft tissue enhancement. In all 4 patients, their abducens nerve (VI) palsy remained. CONCLUSIONS: Delayed CNP can develop despite complete endovascular obliteration of the CCF. The cause of delayed CNP is not yet determined, but may represent fibrosis and ischemia. Long-term follow-up is needed even after complete neurological and radiological recovery is attained in the immediate perioperative period.