Painful Oculomotor Palsy Caused by Posterior-Draining Dural Carotid Cavernous Fistulas

Spontaneous resolution of ophthalmologic symptoms following bilateral traumatic carotid cavernous fistulae

“…1 This is likely due to neural compression by an expanding cavernous sinus or inferior petrosal sinus, venous congestion and thrombosis, vascular steal with ischemia to the blood supply, or any combination of these etiologies. [8][9][10][11] Ophthalmologic sequelae may include open-angle glaucoma, glaucoma secondary to neovascularization, retinal ischemia, central retinal artery occlusion, and, as seen in our patient, central retinal vein obstruction (CRVO). [12][13][14] CRVO not associated with CCF has been found to be the result of thrombus formation within the central retinal vein at the level of the lamina cribrosa.…”

Absence of orbito-ocular signs in dural carotid–cavernous sinus fistula with a prominent anterior venous drainage

“…The fistula drainage often changes from posterior to anterior, and the clinical manifestation progresses to the congestive orbitoocular features (''delayed red-eyed shunts'') [4]. This case showed anterior (SOV) and superior (SMCV) venous drainages as well as posterior (IPS) venous drainage on angiogram, and the SOV was the most prominent.…”

“…Headache and diplopia, which developed separately in this case, are the principal symptoms of posterior draining dural CCF (''white-eyed cavernous shunts'') [4]. The fistula drainage often changes from posterior to anterior, and the clinical manifestation progresses to the congestive orbitoocular features (''delayed red-eyed shunts'') [4].…”

“…However, types B, C and D (slow-flow, dural CCF) have an insidious onset, and show a great variety of clinical manifestations, depending on the direction of venous outflow from the fistula [1,2]. It has been well known that anterior drainage causes congestive orbito-ocular features, due to congestion of the superior ophthalmic vein (SOV), while posterior drainage may result in cranial nerve palsies, probably due to neural compression by an expanding cavernous sinus or inferior petrosal sinus (IPS), venous congestion and thrombosis, vascular steal with ischemia to the blood supply, or a combination of these mechanisms [1][2][3][4][5][6]. However, few cases have shown the absence of orbitoocular signs, despite the presence of a prominent anterior drainage [7 -9].…”

When is diplopia strongly suggestive of a vascular event?

“…While anteriorly draining carotid cavernous fistulas are easy to diagnose, based on signs of orbital congestion (red eye syndrome), posteriorly draining carotid cavernous fistula may be misleading, since they present with isolated and sometimes painless ophthalmoplegia in up 30% of cases [7,8,27,28]. Brain CT and CT angiography seem to be insufficient to make the diagnosis and MRI/MRA are of value in the initial evaluation [28].…”