Management of Acute Orbital Hemorrhage With Obstruction of the Ophthalmic Artery During Attempted Coil Embolization of a Dural Arteriovenous Fistula of the Cavernous Sinus

Abstract

Because of inability to access a cavernous-carotid fistula through conventional means, a superior ophthalmic vein approach was used to allow access for embolization. Although there was initially robust flow through both the fistula and the ophthalmic artery on angiography, the flow stopped during the procedure, and the patient was found to have an orbital hemorrhage. Immediately on emergent canthotomy and evacuation of the hemorrhage, angiographic evidence of restoration of flow was noted. This finding suggests that vision loss in orbital compartment syndrome may be due to arterial occlusion in some cases, and may be reversible if prompt action is taken.

Carotid-cavernous fistula: current concepts in aetiology, investigation, and management

“…19,31,61,65,66 Reported complications include ocular motor nerve palsies; trigeminal sensory neuropathy; brainstem infarction; significant IOP elevation; intracranial haemorrhage; pulmonary emboli; and orbital haemorrhage in the setting of the SOV or inferior ophthalmic vein approach. 61,[65][66][67][68] In addition, a case of inappropriate antidiuretic hormone secretion (SIADH) has been reported, which the authors attributed to disruption of posterior pituitary blood supply by the Onyx used for embolization. 69 Although the risk involved necessitates careful patient selection, successful endovascular treatment can lead to marked improvement in signs and symptoms ( Figure 11).…”

Combined Surgical and Endovascular Access of the Superficial Middle Cerebral Vein to Occlude a High-Grade Cavernous Dural Arteriovenous Fistula: Case Report

“…A severe potential complication is retroorbital hemorrhage caused by perforation of the deep SOV or anterior CS that requires urgent decompression via a canthotomy. 17 A more invasive approach by a lateral orbitotomy has been used to puncture the SOV beyond an anterior stenosis. 18 A direct puncture of either the inferior ophthalmic vein or the CS itself has been described via a small incision in the lateral lower eyelid and advancement of an 18-gauge cannula along the orbital floor toward the medial superior orbital fissure under fluoroscopic control and road mapping of the ipsilateral ICA.…”

Orbital Congestion Complicating Treatment of Cerebral Vascular Anomalies

“…OCS is an ophthalmic emergency characterized by an acute rise in orbital pressure from a rapid increase of volume within the confined space of the orbit (6). Markedly elevated orbital pressure can compromise blood flow to the optic nerve, retina, and choroid, and cause direct nerve compression (14), all of which can result in irreversible blindness if not addressed emergently. While radiologic studies may demonstrate orbital hemorrhage, emphysema, or a tented posterior globe, the diagnosis of OCS is clinical and should not be delayed for imaging or diagnostic testing (3).…”

“…It may also be seen as a complication of orbital or sinus surgery, retrobulbar injection, hemorrhage from vascular anomalies, endovascular procedures, blood dyscrasias, orbital infection, inflammation, tumor, or foreign bodies (3, 14). Cases have also been attributed to operative prone positioning, direct pressure from neurosurgical scalp flaps, and massive fluid resuscitation following burn injury (5, 10, 12).…”