Download Iatrogenic Carotid Cavernous Sinus Syndrome

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Iatrogenic Carotid Cavernous Sinus Syndrome
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M I C H A E L G. HUMMER, M . D . , A N D THOMAS J. C A R L O W ,
M.D.
SUMMARY A hemodlalysls shunt site, subclavian artery to internal jugular rein, resulted in a "pseudo"
cavernous sinus syndrome. Recognition of this rare iatrogenic complication may assist in selecting other shunt
sites and prevent potential visual loss and multiple surgical procedures.
Stroke, Vol 12, No 5, 1981
THE FULLY DEVELOPED clinical picture of a
carotid cavernous sinus fistula (CCF) is not a
diagnostic dilemma. These vascular malformations
commonly are either traumatic or spontaneous.1 This
report is of a iatrogenic instance with clinical signs
and symptoms of a carotid cavernous sinus syndrome
following a subclavian artery to internal jugular vein
shunt.
History
A 62-year-old right-handed man had received 6
years of hemodialysis treatment for membranous
glomerulonephritis. Multiple episodes of thrombophlebitis eventually consumed all common sites for
peripheral hemodialysis fistulas. Renal transplantation was unsuccessful. Since all peripheral shunt sites
had failed, a left subclavian artery to left internal
jugular vein shunt was selected. Within three weeks
after the anastomosis, he experienced holocephalic
headaches and mild generalized weakness, worse on
his right side. A slow but progressive reddening of his
left eye was noted. He denied diplopia, subjective
bruit, pain and decreased visual acuity.
Neurological examination documented a mild but
distinct pronation drift of the right arm without tendon reflex asymmetry. Ophthalmologic examination
revealed a marked dilation and arterialization of the
left conjunctival vessels and 2 mm of left proptosis
From the Veterans Administration Medical Center, Department
of Neurology, University of New Mexico School of Medicine,
Albuquerque, NM 87108.
Reprints: Dr. Carlow, VA Medical Center, Neuro-Ophthalmology Laboratory, Bldg. 13, 2100 Ridgecrest SE, Albuquerque,
NM 87108.
(fig. 1). An ocular bruit was not heard and both globes
were neither tender nor pulsating (utilizing a Schi^tz
tonometer). Visual acuity was correctable to 20/25 on
the right and 20/20 on the left. Pupils were 4 mm
bilaterally and equally responsive to light and accomodation. Applanation tonometry readings were 12
mm Hg on the right and 10 mm Hg on the left.
Vergence, version and duction extraocular movements
were normal. Fundus examination showed mild dilation of the left retinal veins.
Abnormal laboratory studies included: BUN 64
mg/dl, creatinine 8.5 mg/dl, total protein 5.4 gm/dl,
albumin 2.9 gm/dl, prothrombin time 25.7 seconds
(control 11.8) and partial thromboplastin time 67.3
seconds (normal less than 40 seconds). Urinalysis
revealed a specific gravity of 1.017, 2+ glucose, 3+
protein, 2-6 wbc/hpf, and 1-3 casts/lpf.
An EEG showed slowing and decreased amplitude
over the left frontal area. The CT scan suggested a left
frontal chronic subdural hematoma. Within a week
after the subdural was evacuated the right sided
weakness and the EEG improved markedly.
A left carotid arteriogram, after removal of the subdural hematoma, showed slow arterial filling of the
left cerebral hemisphere with all venous drainage from
that side via the right transverse sinus and right internal jugular vein. A left subclavian arteriogram
documented left cavernous sinus arterialization from
retrograde flow in the left internal jugular vein,
transverse sinus and petrosal sinus. Blood flow was
from the shunt into the left carotid cavernous sinus
(fig. 2). Since venous drainage from the left cerebral
hemisphere occurred through the right internal jugular
vein, the left internal jugular vein was ligated above
the fistula. Two months later the patient was symptom
STROKE
VOL. 12, No
5, SEPTEMBER-OCTOBER
1981
FIGURE 1. Iatrogenic carotid cavernous
fistula syndrome. The left conjunctival vessels
are engorged and distended (arrow) compared
to the right normal conjunctival vasculature.
free and the injection in his left eye, proptosis and
retinal signs had resolved. He was maintained on
home peritoneal dialysis.
Discussion
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This patient's constellation of symptoms and signs
are similar to those of the classical carotid cavernous
sinus fistula syndrome. Since the vascular shunt was
not in the cavernous sinus but at a more distal site, the
term "pseudo" carotid cavernous sinus syndrome
seems appropriate.
Cavernous sinus arteriovenous communications in-
elude direct carotid cavernous fistulas (CCF) and
dural meningeal shunts.1 A CCF was first described by
Benjamin Tavers in 1811.1 He diagnosed a pulsating
exophthalmos as an arteriovenous fistula and treated
the CCF by ligating the common carotid artery.
CCF's can be divided into 3 types: spontaneous
(25%), traumatic (75%)' and iatrogenic. The fully
developed CCF syndrome includes: ocular bruit
(75%), pulsating exophthalmos (69%), diplopia (24%),
conjunctival chemosis (36%), orbital pain (16%), and,
less frequently, dilated and arterialized conjunctival
vessels, decreased visual acuity, headache and increased intraocular pressure.* Angiographic delineation with magnification and subtraction techniques
can differentiate and delineate the involved vessels.
Iatrogenic causes have been described following
percutaneous retrogasserian procedures,' secondary to
transsphenoidal surgery* or Fogarty catheter carotid
thromboendarterectomy.7> 8 The iatrogenic CCF
documented here has not been previously reported.
The pathogenesis and treatment of CCF are beyond
the scope of this report but several excellent articles
and reviews are available.*110 A fistula may disappear
spontaneously in 5 to 10 percent of patients.11- " Balloon-catheter techniques1'1" and thrombotic methods'- " that preserve the carotid circulation appear to
be highly satisfactory alternatives to entrapment procedures. The primary surgical objective is to prevent
hypoxic ocular sequelae with attendant visual loss.16
Recognition of the potential complication of a subclavian artery to internal jugular vein shunt may help
to eliminate this locale as a possible hemodialysis
shunt site. Prompt surgical correction can prevent
visual loss.
References
FIGURE 2. Left subclavian artery to left internal jugular
surgical shunt. (S = shunt. IJ = internal jugular vein, EJ =
external jugular vein, I = innominate vein, closed arrow =
proximal end of shunt, open arrow = distal end of shunt,
asterisk = tip of transfemoral catheter).
1. Glaser JS: Neuro-Ophthalmology, Hagerstown, Harper and
Row, pp 336-338, 1978
2. Tavers BA: A case of aneurysm by anastomosis in the orbit,
cured by ligation of the common carotid artery. Trans Med
Clin 2: 1-16, 1811
3. Parsons TC, Guller EJ, Wolff HG, Dunbar HS: Cerebral
angiography in carotid cavernous communications. Neurology
(Minneap) 4: 65-68, 1954
4. Sanders MD, Hoyt WF: Hypoxic ocular sequelae of carotid
cavernous fistula. Study of the causes of visual failure before
and after neurosurgical treatment in a series of 25 cases. Br J
Ophthalmol 53: 82-97, 1969
5. Sekhar LN, Heros RC, Kerber CW: Carotid cavernous fistula
following percutaneous retrogasserian procedures. Report of
two cases. J Neurosurg 51: 700-706, 1979
6. Takahashi M, KillefTer F, Wilson G: Iatrogenic carotid cavern-
IATROGENIC CAROTID CAVERNOUS SINUS SYNDROME/Hummer and Carlo*
ou3 fistula; case report. J Neurosurg 30: 498-500, 1969
7. Barker WF, Stern WE, Krayenbuhl H, Senning A: Carotid
endarterectomy complicated by carotid cavernous sinus fistula.
Ann Surg 167: 568-572, 1968
8. David JC, Richardson R: Distal internal carotid thromboembolectomy using a Fogarty catheter in total occlusion: technical note. J Neurosurg 27: 171-177, 1967
9. Mullan S: Treatment of carotid cavernous fistulas by cavernous
sinus occlusion. J Neurosurg 50: 131-144, 1979
10. Hosobuchi Y: Carotid cavernous fistula. In Wilson CB, Hoff JT
(eds) Current Surgical Management of Neurologic Disease.
New York, Churchill Livingstone, pp 169-181, 1980
11. Potter JM: Carotid cavernous fistula: Five cases with "spon-
691
taneous" recovery. Br Med J 2: 786-788, 1954
12. Dandy WE: The treatment of carotid cavernous arteriovenous
aneurysms. Ann Surg 102: 916-926, 1935
13. Serbinenko FA: Balloon catheterization and occlusion of major
cerebral vessels. J Neurosurg 41: 125-145, 1974
14. Debrun G, Lacour P, Caron J-P et al: Detachable balloon and
calibrated-leak balloon techniques in the treatment of cerebral
vascular lesions. J Neurosurg 49: 635-649, 1978
15. Hosobuchi Y: Electrothrombosis of carotid cavernous fistula. J
Neurosurg 42: 76-85, 1975
16. Spencer WH, Thompson HS, Hoyt WF: Ischaemic ocular
necrosis from carotid-cavernous fistula. Br J Ophthalmol 57:
145-152. 1973
Transient Vertical Monocular Hemianopsia
with Anomalous Retinal Artery Branching
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E D W A R D R. W O L P O W , M . D . AND RICHARD G. L U P T O N
SUMMARY A 62-year-old man reported 6 stereotyped attacks of transient loss of vision in the lateral visual
field of the right eye and was subsequently found to hare right internal carotid artery occlusion. Fundoscopy
revealed an anomalous central retinal artery branching whereby a single stem vessel supplied the superior and
inferior nasal quadrants of the retina. Circulatory Insufficiency in this anomalous stem could explain the occurrence of vertical monocular bemianopsia as an unusual manifestation of ipsilateral carotid artery atherosclerosis.
Stroke, Vol 12, No 5, 1981
TRANSIENT monocular blindness as an indicator of
ipsilateral internal carotid artery atheroma was first
emphasized by Fisher.1 When the transient blindness
is not total, a horizontal hemianopsia or a quadrantanopsia is most often reported by the patient.* This is
consistent with the usual pattern of arterial supply to
the retina whereby a single superior and inferior
branch of the central retinal artery supplies a territory
above and below the optic disc.
This patient presents an instance of vertical
monocular hemianopsia that may have been due to an
appropriate retinal vascular anomaly. In such a
patient, description of a vertical monocular hemianopsia might be interpreted by the physician to represent
a misreporting of a homonymous hemianopsia.
Report of the Patient
With no previous history of retinal or cerebral
vascular disease, a 61-year-old hypertensive man
described 2 spells per day for 3 consecutive days of
loss of vision in the temporal half visual field of the
right eye lasting about one minute each time. He had
been careful to cover each eye separately and was
quite certain the field loss was as reported.
Hospitalization was advised but he put this off for 11
months. During this time there were no transient or
permanent retinal or cerebral attacks. Examination of
the right ocular fundus (fig.) showed an anomalous
retinal arteriolar pattern whereby a single common
From the Division of Neurology, Mt. Auburn Hospital, Cambridge, MA 02138.
stem bifurcated (arrow) to supply the superior and inferior nasal quadrants. The temporal quadrants were
supplied in the usual fashion and the vascular pattern
of the left ocular fundus was normal. No embolic
material was noted. Transfemoral angiography
showed total occlusion of the right internal carotid
artery just distal to its origin. Blunting of the stump
suggested an old occlusion.
Discussion
Transient monocular vertical hemianopsia has been
described only rarely2-' and an adequate explanation
for it has not been provided. Permanent monocular
vertical hemianopsia has been reported as an uncommon result of emboli to the superior and inferior
retinal artery branches on the same side of the retina.4
The basic anatomical pattern of division of the central retinal artery into a superior and an inferior
retinal artery is only rarely anomalous and global,
altitudinal or quadrantic field loss is to be expected.
There is variation as to where, in relation to the optic
disc, the division into a superior and an inferior retinal
artery branch occurs.8 Single instances have been
reported in asymptomatic individuals where one central retinal artery branch divides to supply the
superior and the inferior nasal or temporal half of the
retina.'"8 The only large-scale search for such
anatomical variations was undertaken by Awan9 who
found, on examining the eyes of 2100 people, that the
temporal half-retina was supplied by a single
branching artery in 19 eyes and the nasal half-retina
Iatrogenic carotid cavernous sinus syndrome.
M G Hummer and T J Carlow
Stroke. 1981;12:689-691
doi: 10.1161/01.STR.12.5.689
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Copyright © 1981 American Heart Association, Inc. All rights reserved.
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