Bilateral Carotid-Cavernous Fistula: A Diagnostic and Therapeutic Challenge

Sharma, Rohan; Ponder, Christian; Kamran, Mudassar; Chacko, Joseph G.; Kapoor, Nidhi; Mylavarapu, Krishna; Onteddu, Sanjeeva; Nalleballe, Krishna

doi:10.1177/23247096221094181

Cited by 3 publications

(1 citation statement)

References 25 publications

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“…The decrease in the pressure gradient between the ICA and the fistula may result in thrombosis of the feeding arteries and subsequent fistula closure because of stagnation and reduced blood flow [ 19 ]. Intravascular intervention such as coil embolization should be considered if patients show indications of increased IOP, exophthalmos or proptosis, decreased vision, ophthalmoplegia, or persistent headaches [ 20 ].…”

Section: Discussionmentioning

confidence: 99%

Low-Flow Type-D Bilateral Dural Carotid-Cavernous Fistula Diagnosed by 3-Dimensional Time-of-Flight Magnetic Resonance Angiography with Post-Treatment Follow-Up

Balodis,

Kalējs,

Migunova

2024

Am J Case Rep

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Patient: Female, 62-year-old Final Diagnosis: Bilateral dural carotid cavernous fistula Symptoms: Bilateral periorbital edema • conjunctival chemosis • diminished visual acuity • diplopia • ophthalmoplegia Clinical Procedure: Endovascular coil embolisation Specialty: Ophthalmology • Radiology Objective: Rare disease Background: Carotid-cavernous fistula (CCF) is a rare, atypical vascular shunt between the carotid arterial system and the venous channels of the cavernous sinus, classified according to the shunt’s anatomy, by etiology (resulting from trauma or occurring spontaneously), or by hemodynamic characteristics (such as low- or high-flow fistulas). Case Report: A 62-year-old female patient with poorly controlled arterial hypertension presented with bilateral periorbital edema, conjunctival chemosis, ophthalmoplegia, diplopia, and diminished visual acuity. On magnetic resonance angiography (MRA), abnormal arterial flow along the cavernous sinuses was noted, suggestive of bilateral CCF. The diagnosis of indirect dural low-flow CCF (Barrow Type D) was later confirmed by digital subtraction angiography, with feeding arteries from intracavernous internal carotid artery branches, and meningeal branches of the external carotid artery, draining bilaterally to ophthalmic veins, the intracavernous sinus, and the inferior petrosal sinus. The patient was successfully treated with endovascular embolization. At 7-month follow-up, no residual arteriovenous shunting was detected. This case highlights the importance of non-invasive radiological methods for CCF, and presents rarely published radiological findings of bilateral Type-D dural CCFs on 3-dimensional time-of-flight MRA with post-treatment MRA follow-up. Conclusions: Regardless of the patient’s history of possible trauma, a patient presenting with bilateral periorbital edema, conjunctival chemosis, ophthalmoplegia, diplopia, and diminished visual acuity should have a spontaneous bilateral CCF investigated to prevent delayed treatment. Experienced neuroradiologists are needed to accurately detect indirect CCF, since this condition often does not demonstrate classic symptoms.

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Section: Discussionmentioning

confidence: 99%

Low-Flow Type-D Bilateral Dural Carotid-Cavernous Fistula Diagnosed by 3-Dimensional Time-of-Flight Magnetic Resonance Angiography with Post-Treatment Follow-Up

Balodis,

Kalējs,

Migunova

2024

Am J Case Rep

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Features of differential diagnosis of direct carotid-cavernous fistula. Clinical case

Tabashnikova

Serova

Yakovlev

2023

Ophthalmology Reports

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Traumatic brain injury can cause various pathological conditions both in the eyeball and in the cranial cavity. The presented clinical case demonstrates the features of differential diagnosis of direct carotid-cavernous fistula and secondary post-traumatic glaucoma. Direct carotid-cavernous fistula is the formation of a communication between the internal carotid artery and the cavernous sinus and the discharge of arterial blood into it. The first symptom of a carotid-cavernous fistula is a pulsating noise in the head and above the eye. The manifest signs in the clinical picture are the signs of obstruction of venous outflow from the eye and the orbit: proptosis, eyelid edema and chemosis, congestive redness of the eye, varicose subcutaneous veins of the eyelids, as well as dilated ophthalmic vein visualized by ultrasound of the orbit, ophthalmic hypertension, oculomotor disorders, state of the fundus. The clinical picture in patients with secondary post-traumatic contusion glaucoma, in addition to an increase in intraocular pressure, is characterized by the presence of a congestive redness of the eye, changes in the cornea from mild superficial opacities to more dense ones, luxation or subluxation of the lens into the anterior chamber or vitreous, destruction of the vitreous or intraocular hemorrhage. The similarity of clinical manifestations of traumatic carotid-cavernous fistula and secondary post-traumatic glaucoma can cause difficulties in differential diagnosis.

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Complexity in the diagnosis of endocrine ophthalmopathy with a carotid-cavernous fistula. A clinical case

Tsyplina,

Pochechueva,

Yanchenko

et al. 2024

jour

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Introduction. Clinical cases featuring a combination of endocrine ophthalmopathy with a carotid-cavernous fistula are scarce, with only four cases documented in the literature, thus posing a diagnostic challenge due to overlapping clinical symptoms. A carotid-cavernous fistula with high blood flow typically presents a clear clinical picture. However, low-flow variants are challenging to timely diagnose. A history of head trauma can be an essential diagnostic clue, as carotid-cavernous anastomosis develops in 75% of cases post-trauma and in 25% spontaneously. Bilateral carotid-cavernous fistulas are particularly rare.Purpose: to present the clinical features and outcomes of bilateral endocrine ophthalmopathy associated with a non-traumatic carotid-cavernous fistula, based on the prospective observation of a patient treated in various city healthcare hospitals during 2021–2022.Case description. The patient first visited the ophthalmologist in October 2021, presenting with bilateral exophthalmos, edema, and eye redness. A positive test for antibodies to thyroid-stimulating hormone and enlargement of the eye muscles, confirmed by orbital ultrasound, led to a diagnosis of “Endocrine Ophthalmopathy”. The patient’s condition was managed jointly by an endocrinologist and an ophthalmologist. Over two months, a worsening of ocular symptoms was observed, prompting a neurosurgical consultation. Cerebral angiography conducted in a hospital setting confirmed a carotid-cavernous fistula. An endovascular procedure was performed five months after the initial ocular symptoms appeared to separate the carotid-cavernous anastomosis on the right using a non-adhesive composition. Ocular symptoms resolved within 2–3 weeks post-surgery.Conclusions. Clinical manifestations of carotid-cavernous fistulas can resemble those of endocrine ophthalmopathy. The absence of a traumatic head injury history, complaints of unilateral head noise synchronous with the pulse, and the bilateral nature of the symptoms complicated the diagnosis of this neurosurgical pathology in a patient with endocrine ophthalmopathy. It is crucial to include both conditions in the differential diagnosis and to employ a multidisciplinary approach for effective management.

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Bilateral Carotid-Cavernous Fistula: A Diagnostic and Therapeutic Challenge

Cited by 3 publications

References 25 publications

Low-Flow Type-D Bilateral Dural Carotid-Cavernous Fistula Diagnosed by 3-Dimensional Time-of-Flight Magnetic Resonance Angiography with Post-Treatment Follow-Up

Low-Flow Type-D Bilateral Dural Carotid-Cavernous Fistula Diagnosed by 3-Dimensional Time-of-Flight Magnetic Resonance Angiography with Post-Treatment Follow-Up

Features of differential diagnosis of direct carotid-cavernous fistula. Clinical case

Complexity in the diagnosis of endocrine ophthalmopathy with a carotid-cavernous fistula. A clinical case

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