Long Delayed Traumatic Carotid-Cavernous Sinus Fistula

Abstract

Traumatic carotid-cavernous sinus fistula (TCCF) is a rare but significant vascular abnormality in the skull base found after craniomaxillofacial trauma. Although the direct type is usually caused by trauma, the onset of symptoms in TCCF may present several weeks after injury. We present the case of a patient who sustained a blunt head injury from falling down and was hospitalized with skull base fracture associated with zygomatic complex fractures on the right side. After surgery, the recovery was uneventful and the patient was discharged without any problems. On the eighth week postoperatively, the patient returned to hospital presenting tinnitus, bruit on the right orbital area, diplopia, eye pain, and headache. The patient also had severe limitation of ocular movement on lateral gaze. After having brain angio-CT, which showed a dilated superior ophthalmic vein, the diagnosis of CCF with cranial nerve VI was confirmed. The fistula was occluded successfully by using coils. After the procedure, tinnitus, bruit, and headache were reduced immediately. On following up 4 months after coiling, cranial nerve VI palsy and related symptoms-diplopia and limit of ocular movement-were improved significantly. Although TCCFs usually manifest symptoms early after trauma, in this case, the patient presented clinical signs 8 weeks post-injury, while the longest time that was acknowledged in another previously released article was 6 weeks. According to this case, we recommend a careful follow-up until 2 months for patients with skull base fracture in order to rule out the risk of CCF.

A rare case report of complications in craniofacial injuries

“…This indicates the presence of a fistula; it also measures its size, determines the flow to the distal supraclinoid vessels, and most importantly indicates the competency of the circle of Willis and contralateral carotid circulation. [15,16]…”

“…The detachable balloon approach is considered by most neurosurgeons to be the best initial therapy. [16] However, percutaneous balloon embolization is currently the procedure of choice, because it allows preservation of the ICA. A previous study has reported that the success rate of balloon embolization is 80%.…”

Fistula carótido-cavernosa unilateral con síntomas neuro-oftalmológicos bilaterales e infarto cerebral venoso: Reporte de un caso.

“…En el caso de nuestra paciente, el diagnóstico se realizó 4 meses después del evento traumático, con sintomatología progresiva que inició a la semana del mismo y gran compromiso neuro-oftalmológico, lo que no concuerda con la bibliografía en donde se describe que como regla, las fístulas directas (alto flujo) son de presentación brusca y dramática, con un desarrollo súbito de la "tríada de Dandy" que incluye exoftalmos pulsátil, soplo orbitario y quemosis conjuntival (16) aunque se han descrito periodos de hasta 8 semanas para el inicio de los síntomas (17).…”

Endovascular repair of direct carotid–cavernous fistula in Ehlers–Danlos type IV

“…Multiple etiologies are implicated in direct CCF, including basilar skull fracture or blunt force trauma. 4 In contrast, spontaneous causes include rupture of an ICA cavernous aneurysm. In collagen tissue disorders such as EDS IV, fibromuscular dysplasia and pseudoxanthoma elasticum, the proposed mechanism is a spontaneous dissection of the ICA with pseudoaneurysm formation.…”