Download Delayed Traumatic Caroticocavernous fistula

Case Report
Delayed Traumatic Caroticocavernous fistula
Dr.A.Kowsalya, Dr.S.Mahesh Kumar, Dr. Tushar Grover, Aravind Eye Hospital, Madurai
Case Reort
Caroticocavernous fistula is an abnormal
communication between the Cavernous Sinus and
the Carotid Arterial system. CCF can be classified
based on 1.Etiology (Traumatic/ Spontaneous),
2. Velocity of blood flow (High or low) and
3.Anatomy (Direct vs. Dural, Internal Carotid
vs. External Carotid vs. both).1 Direct CCFs are
caused by a single traumatic tear in the arterial wall
following Head Trauma, Penetrating Orbitofacial
injuries, causing direct connection between the
Cavernous segment of Internal Carotid Artery
and Cavernous Sinus. These fistulas are of high
flow type. Here we describe a young patient who
presented as a case of Traumatic third nervepalsy,
developed Direct Carotico cavernous Fistula
a month later, well managed and recovered.
Although TCCFs usually manifest symptoms early
after trauma, in this case, the patient presented
clinical signs 6 weeks post-injury, which was also
the longest time reported in previous literature.2
A 32 yrs old male presented to us in August
2012, with complaints of Double vision for 15
days which was binocular on looking towards
the right side. He gave history of head injury in
a Road Traffic accident 1month back with loss
of consciousness for 30 minutes and nasal bleed.
Diplopia was more on looking towards right
side and it was binocular. He had pain on left
gaze. On examination, his general condition
was good. His best corrected visual acuity in
both eyes was 6/6. Left eye was exotropic and
hypertropic with mild ptosis and mid dilated
non-reacting pupil. There was restriction of
elevation, depression, and adduction in the left
eye. Fundus of right eye was normal and left eye
showed resolved Berlin’s edema. Colour vision
and Central fields were normal in both eyes. Hess,
Diplopia charting showed incomplete third nerve
palsy in the left eye. His higher functions, sensory
and motor system were normal. All other Cranial
nerves were normal. There were no cerebellar
signs or gait disturbance. CT Brain showed
fracture of left frontal bone extending to frontal
sinus and orbit with subarachnoid hemorrhage.
With the above findings a diagnosis of Traumatic
Incomplete, pupil involving Third nerve palsy
(Left eye) was made and given assurance and
advised review after a month. 15 days later, he
presented with history of sudden protrusion of
eyeball, redness, blurred vision in the left eye for
3 days with no diplopia. He also complained of
an abnormal blowing sound (pulsatile tinnitus)
in the left ear for 3 days. On examination, left
eye showed proptosis, severe circumcorneal
congestion, corkscrew shaped vessels, chemosed
forniceal conjunctival vessels inferiorly (Fig 1,
Fig 1 : Carotico cavernous Fig 2 : Carotico cavernous
fistula – cork screw
fistula Proptosis,
vessels
conjunctival chemosis
2). Anterior chamber showed exfoliative material
and the pupil was 6mm dilated and fixed and
adduction, abduction, depression were completely
restricted with minimal restriction of elevation.
(Fig 3). Intraocular pressure was 30 mmHg in
the left eye and the visual acuity had dropped
to 6/60. A clinical diagnosis of Posttraumatic
Carotico Cavernous fistula (left side) was made.
Vol. XVI, No.2, April - June 2016
33
Internal Carotid Artery (Fig 6). Hence DSA
Intervention with Balloon embolisation and
complete obliteration of fistula was done (Fig
Fig 3 : Total External Ophthalmoplegia
MRI/MRA Brain was done, which showed Dilated
Superior Ophthalmic vein and Cavernous sinus on
left side suggestive of CCF (Fig 4, 5). The patient
was referred to a higher institute of Neurosciences.
Fig 7 : DSA – Post balloon embolization
Fig 4 : MRA Brain Carotico cavernous fistula
Fig 5 : MRI/MRA Brain – Dilated Superior ophthalmic
vein with Carotico cavernous fistula
Digital Subtraction Angiography (DSA) revealed
a rent measuring 3.5mm in the posteroinferior
segment of the horizontal segment of Cavernous
Fig 8 : Post procedure - Complete obliteration of
the fistula
Fig 6 : DSA – Rent in the horizontal segment of
Cavernous Internal Carotid Artery
7, 8). Patient came for review with us 9 days
after the procedure with significant symptomatic
improvement (Fig 9). One month later his bestcorrected visual acuity was 6/6 in the left eye and
had regained all movements except abduction
and 6 months later he had recovered completely
(Fig 10).
34
AECS Illumination
Fig 9 : 1 month post procedure - Significant recovery
of proptosis and extraocular movements
Fig 10 : 6 moths review – complete recovery of
proptosis and all extraocular movements
Discussion: Barrow3 classifies CCF as Types
A, B, C, D. Type A or Direct- Direct connection
between the cavernous segment of the Internal
Carotid artery and the cavernous sinus. Type B Abnormal communication between the cavernous
sinus and one or more meningeal branches of
the Internal Carotid artery. Type C – Abnormal
communication between the cavernous sinus and
the meningeal branches of the external carotid
artery. Type D - Abnormal communication
between the cavernous sinus and meningeal
branches of Internal carotid artery and External
carotid artery. Classic symptoms of Carotico
Cavernous Fistula include exophthalmos, orbital
or cephalic bruit, ocular hypertension, severe
orbital pain, headache, conjunctival and episcleral
injection, chemosis, extraocular muscle palsies and
visual deterioration. The signs and symptoms vary
according to the size and location of the lesion as
well as the predominant venous drainage.4 In high
flow Direct CCF, there is usually rapid onset of
redness, proptosis, and chemosis of one or both
eyes often associated with ophthalmoplegia and
bruit. Venous stasis retinopathy or ischemic central
retinal vein occlusion may develop in few patients.5
Episceral and conjunctival vessels become dilated
with arterial blood (Arterialisation) and have a
corkscrew configuration.5
Orbital Ultrasound has been used in the
diagnosis of fistulas.4,6 The key findings are Dilated
Superior ophthalmic vein and congestion of the
orbital issue including mild thickening of all the
extra ocular movements. The next method of
assessing CCFs is Neuro Imaging- CT Doppler,
MRI/MRA. Findings include dilated superior
ophthalmic vein, asymmetric enlargement of the
extraocular muscles, proptosis, pseudoaneurysm
with bulging of cavernous sinus.4 Intravenous
Digital subtraction Angiography has been used
in evaluating CCF.6
Between 10 and 60% of spontaneous CCFs
will close spontaneously.7 The closure is secondary
to partial or complete thrombosis of the cavernous
sinus or its tributaries.The goal of therapy is to
cure cranial nerve palsies and provide symptomatic
relief for the patients. The most important thing in
considering treatment is to identify a center with
a very low morbidity and mortality rate that has
considerable experience with modern embolization
techniques. Recently balloon/coil embolisation has
been advocated primarily for treating traumatic
fistulas. Balloon/coil positioning is done by an
arterial or venous endovascular approach through
the superior ophthalmic vein. Vinuela et al series
showed a significant clinical improvement in most
of the embolised dural fistulas.
CCF is a rarely life threatening problem.
Loss of vision is the main risk of not treating. On
the other hand the procedures used to treat the
condition carry a small but definite mortality and
a rather significant morbidity.
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35
References
1. Walsh and Hoyt's clinical neurophthalmology. (5th ed) vol 1:1220.
2. Nguyen T, Cho YH, Jang YJ, Park MC, Shin SJ.Long delayed traumatic carotid-cavernous sinus fistula. J
Craniofac Surg. 2013 May;24(3):e237-9
3. Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT. Classification and
treatment of spontaneous carotid cavernous fistulas. J Neurosurg.1985;62:248–56
4. Vinuela F, Fox AJ, Debrun GM, et al. Spontaneous carotid – cavernous fistulas: clinical, radiological, and
therapeutic considerations. J Neurosurg 1984; 60: 976-84
5. Yanoff M, Duker JS. Ophthalmology. 2nd ed. Spain: Mosby; 2004. pp. 1403–4.
6. Santhosh J, Sanjay S. Neurophthalmology. 3rd ed. Aravind Eye Hospital; 1995. Radiology in
neurophthalmolgy: Endovascular interventions in ophthalmology; p. 275.
7. Debrun GM, Vinuela F, Fox AJ, et al. Indications for treatment and classification of 132 carotid –
cavernous fistulas. Neurosurgery 1988 ; 22: 285-9
8. Usha Kim, Mahesh Kumar, et al. Atlas of imaging in Neuro ophthalmology and Orbit, 1st
edition;2009IMAGES: