Ophthalmologic outcome of direct and indirect carotid cavernous fistulas

Abstract

Carotid cavernous fistulas (CCFs) can be classified as direct and indirect, depending on their flow rates and their etiology. Both forms can cause the same characteristic ophthalmological symptoms and signs. We analyzed these ocular characteristics and determined the prognostics factors associated with treatment outcome. Forty-seven patients with an angiographically confirmed diagnosis of CCF, a preoperative ophthalmic evaluation and at least one ophthalmic sign or symptom at the initial presentation were retrospectively evaluated. The patients were followed-up ophthalmically until the end of treatment, and the complications and the remaining ophthalmological signs and symptoms were then recorded. The patients' ages ranged from 13 to 89 years, with an average of 55.78 (±20.73) years, and a predominance of 28 female (57.8 %) patients. The patients with a direct CCF had a lower average age (p = 0.02). The most common symptoms were blurred vision in 17 (36.2 %) and proptosis in 37 (78.7 %) patients. Elevated intraocular pressure (IOP) was more prevalent in patients with an indirect CCF (p = 0.02). Thrill was more prevalent in patients with direct CCF (p = 0.01). The presence of an initial decrease of visual acuity at the first ophthalmic evaluation was significantly associated with the persistence of ocular symptoms after fistula treatment (odds ratio 3.33). In conclusion our study shows a slight difference in ophthalmic symptoms among patients with different types of fistula. Elevated IOP was significantly associated with indirect fistulas, whereas thrill was significantly associated with direct fistulas. The presence of an initial decrease of visual acuity was significantly associated with a worse ophthalmic prognosis.

Secondary glaucoma following carotid cavernous fistula

“…They usually occurs in middle-aged or postmenopausal women, but can occur in any gender or any age (7) . The spontaneous fistulas account for approximately 25% of cases, but the traumatic cause is the most prevalent one (1)(2)(3)(4)(5)(6)(7) .…”

“…The spontaneous fistulas account for approximately 25% of cases, but the traumatic cause is the most prevalent one (1)(2)(3)(4)(5)(6)(7) . The pathogenesis of spontaneous fistulas is controversial; it is believed that the dural fistulas are formed after breaking the fragile wall of one or more dural arteries which normally come out through the cavernous sinus or which are carried out by an attempt to provide a collateral venous flow in response to spontaneous thrombosis of the veins present in the cavernous sinus (7) . Most patients present high high IOP (5,7,9) .…”

“…The pathogenesis of spontaneous fistulas is controversial; it is believed that the dural fistulas are formed after breaking the fragile wall of one or more dural arteries which normally come out through the cavernous sinus or which are carried out by an attempt to provide a collateral venous flow in response to spontaneous thrombosis of the veins present in the cavernous sinus (7) . Most patients present high high IOP (5,7,9) . The mechanism involved in the elevation of IOP is well understood: it is due to the reversion of the arterial blood draining that promotes mixing between arterial and venous blood and leads to a reduction in blood pressure and increase in orbital venous pressure resulting in increased episcleral venous pressure, directly influencing the increased flow resistance of the aqueous humor in the trabecular mesh area (5)(6)(7)(8)(9) .…”

“…Patients may present engorged episcleral and conjunctival veins, minimal proptosis and presence of pulse or puff (8) . Most patients present high intraocular pressure (IOP) (5,7,9) . .…”

New daily persistent headache — rare primary or secondary phenomena caused by carotid-cavernous fistula? A case report

“…There are reports which suggest that headache associated with the above mentioned signs can be a usual presentation of CCF, in up to 40-50% cases [10,11], but rare are those which point out headache as the only clinical symptom of CCF. These, CCF associated headaches, in small number of cases, can be presented as mimicking primary headaches [12], but in our patients it was a rare clinical phenotype of primary headache, NDPH.…”