Communicating carotid-cavernous sinus fistula following minor head trauma

Abstract

IntroductionA case of communicating carotid-cavernous sinus fistula (CCF) after minor closed head injury is presented.Case presentationA 45-year-old Caucasian male presented to the emergency department of a tertiary care hospital with the chief complaint of blurred vision and facial numbness. The patient had experienced a minor head injury 1 month ago with loss of consciousness. After a 2-week symptom-free period, he developed scalp and facial numbness, along with headache and vision problems. His vital signs were within normal limits, but on examination the patient was noted to have orbital and carotid bruits with several concerning neurological findings. CT and MRI confirmed the suspicion of carotid-cavernous sinus fistula, which was managed by cerebral angiography with coil embolization of this fistula. The patient was symptom free at the 8-month follow-up.DiscussionCarotid-cavernous sinus fistula is a rare condition that is usually caused by blunt or penetrating trauma to the head, but can develop spontaneously in about one fourth of patients with CCF. The connection between the carotid artery and cavernous sinus leads to increased pressure in the cavernous sinus and compression of its contents, and thereby produces the clinical symptoms and signs seen. Diagnosis depends on clinical examination and neuroimaging techniques. The aim of management is to reduce the pressure within the cavernous sinus, which results in gradual resolution of symptoms.

Delayed onset diplopia following head trauma

“…A carotid-cavernous sinus fistula develops when the carotid artery leaks into the cavernous system, usually over days to weeks, increasing venous pressure and compressing the cavernous sinus contents. 1 Most occur after blunt or penetrating head trauma, although they can also occur spontaneously. The classic triad of symptoms is chemosis, exophthalmos, and orbital bruit.…”

Advances in the endovascular treatment of direct carotid-cavernous fistulas

“…22 Despite the fact that direct CCFs occur as acute events, the symptoms can be insidious and potentially grave. 4,22 The clinical manifestations are delayed, appearing after venous hypertension has reached a critical level, which may take weeks to happen. 22 In addition, the exuberance of the clinical condition is more related to the venous drainage standard than to the size of the fistula.…”

“…4,22 The clinical manifestations are delayed, appearing after venous hypertension has reached a critical level, which may take weeks to happen. 22 In addition, the exuberance of the clinical condition is more related to the venous drainage standard than to the size of the fistula. 4 There may be compromised cranial nerves III, IV, V and VI, causing extraocular motility paralysis and diplopia, in addition to the appearance of headache, retro-ocular pain, vision loss and even intracranial hemorrhage.…”

“…1,4,24 In addition, the intracavernous pressure can be transmitted to the contralateral CS through the intercavernous sinuses, resulting in bilateral ocular deficits. 4,22 The symptoms usually improve significantly following treatment, many times achieving resolution in hours or days. Total recovery, however, can take weeks or months.…”

“…4 There may be compromised cranial nerves III, IV, V and VI, causing extraocular motility paralysis and diplopia, in addition to the appearance of headache, retro-ocular pain, vision loss and even intracranial hemorrhage. 22 Deteriorated vision occurs due to the combination of the reduction in arterial perfusion and venous hypertension, accompanied by glaucoma and the worsening of the retina perfusion. 1,4 A condition of cerebral ischemia, related to the phenomenon of "vascular theft", seems to be exceptionally rare and occurs only in patients with variations in the Willis polygon.…”