Post-traumatic carotid-cavernous fistula with bilateral proptosis simulating cavernous sinus thrombosis

Kasturi, Nirupama; Kumari, Pooja; Nagarajan, Gayatri; Nagarajan, Krishnan

doi:10.1136/bcr-2018-227757

Cited by 6 publications

(5 citation statements)

References 9 publications

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“…Nevertheless, as this study shows, diagnosing CCFs on CTA can be made difficult by normal anatomic variants, suboptimal timing of the contrast bolus, and asymmetry of structures that are often implicated as imaging evidence of CCFs. Furthermore, patients may present with a wide range of symptoms, which can also confound the diagnosis; nerve palsies, headaches associated with conjunctivitis, painful ophthalmoplegia, symptoms in the contralateral eye, and other non-specific symptoms have all been linked to CCFs (19)(20)(21)(22)(23).…”

Section: Discussionmentioning

confidence: 99%

CT angiogram findings in carotid-cavernous fistulas: stratification of imaging features to help radiologists avoid misdiagnosis

et al. 2019

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Background Carotid-cavernous fistulas (CCFs) are commonly misdiagnosed on computed tomography angiography (CTA). Purpose This study sought to identify the most sensitive and specific imaging features of CCFs on CTA. Material and Methods A retrospective review identified 18 consecutive patients suspected of having a CCF on CTA and subsequently underwent digital subtraction angiography (DSA). Two blinded reviewers assessed multiple findings on CTA: cavernous sinus asymmetry/enlargement; arterial-phase contrast in the cavernous sinus; proptosis; pre- or post-septal orbital edema; and dilated regional vasculature. Each was graded as positive, possible, and negative; “possible” was counted as positive. A third blinded reviewer served as a tiebreaker. Results Of 18 patients, nine were true-positive and nine were false-positive. Superior ophthalmic vein early enhancement and dilatation had 100.0% sensitivity (95% confidence interval [CI] 40.0–100.0) and 77.8% specificity (95% CI 44.4–100.0); arterial-phase contrast in the cavernous sinus had 88.9% sensitivity (95% CI 44.4–100.0) and 66.7% specificity (95% CI 18.5–90.1); peri-orbital edema had 88.9% sensitivity (95% CI 35.5–100.0) and 77.8% specificity (95% CI 22.2–100.0). The most specific markers of CCF were superior petrosal sinus and inferior ophthalmic vein dilatation/enhancement (100.0%, 95% CI 88.8–100.0 and 88.9%, 95% CI 44.4–100.0, respectively); the specificity of asymmetric cavernous enlargement was 44.4% (95% CI 11.1–77.7). Conclusions Among patients in whom a CCF is suspected on CTA, superior ophthalmic vein dilatation/enhancement and arterial-phase contrast within the cavernous sinus are the most sensitive findings. Asymmetric cavernous sinus enlargement has poor specificity and may result in false-positive diagnoses of CCFs. False positive cases were less likely to have an optimally timed contrast bolus.

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Section: Discussionmentioning

confidence: 99%

CT angiogram findings in carotid-cavernous fistulas: stratification of imaging features to help radiologists avoid misdiagnosis

et al. 2019

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“…CVST and CCF are rare complications of penetrating head trauma [ 3 , 4 ]. The diagnoses of CVST and CCF are difficult even with advanced neuroimaging because the signs and symptoms can be varied and non-specific.…”

Section: Discussionmentioning

confidence: 99%

“…A carotid cavernous fistula (CCF) is an abnormal connection between the cavernous sinus and the carotid arterial system. CCF is a very rare complication of head trauma, especially basal skull fracture [ 3 , 4 ]. We report a unique case of a penetrating brain injury by a needlefish causing orbital cellulitis, retro-orbital abscess, CVST and CCF.…”

Section: Introductionmentioning

confidence: 99%

Stick a Needle in My Eye: A Case Report of Penetrating Needlefish Injury Causing Cavernous Sinus Thrombosis and Carotid Cavernous Fistula

Alfaheed¹,

Campos²,

Gupta³

et al. 2023

Cureus

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While swimming in the ocean on vacation in Cuba, a previously healthy 17-year-old female was unexpectedly stabbed through her orbit and into her brain by a needlefish. This is a unique case of a penetrating injury causing orbital cellulitis, retro-orbital abscess, cerebral venous sinus thrombosis and carotid cavernous fistula. After initial management at a local emergency department, she was transferred to a tertiary care trauma centre where she was treated by a team of emergency, neurosurgery, stroke neurology, ophthalmology, neuroradiology and infectious disease physicians. The patient faced a significant risk of a thrombotic event. There was careful consideration from the multidisciplinary team about the utility of thrombolysis or an interventional neuroradiology procedure. Ultimately, the patient was treated conservatively with intravenous antibiotics, low molecular weight heparin and observation. The patient continued to show clinical improvement several months later, which supported the challenging decision to opt for conservative management. There are very few cases to guide the treatment of this type of contaminated penetrating orbital and brain injury.

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“…In the literature review, we found cavernous sinus embolism is almost invariably septic and is usually associated with a primary infective source in the face, throat, mouth, ear, mastoid, or in the sphenoidal, ethmoidal, or maxillary sinuses ( 4 – 7 ). Aseptic cavernous sinus embolism is a rare occurrence and has been described to be associated with head injury, surgical procedures of the fifth nerve, and carcinomatous invasion of the base of the skull ( 8 – 10 ). To our knowledge, venous tumor thrombus progressed cranially to the suprasellar region with painful ophthalmoplegia as the first manifestation of aseptic cavernous sinus embolism has not been previously reported.…”

Section: Discussionmentioning

confidence: 99%

Case report: 18F-FDG PET confirmed pupil-sparing third nerve palsy heralding aseptic cavernous sinus embolism in patient with chest malignancy

Xiong

Liu²,

Li³

et al. 2022

Front. Surg.

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Classical cavernous sinus embolism is a rare clinical finding, presented most commonly by complaints of headache, diplopia, visual field defects, facial pain, and progressive neurological deficits. Many patients exhibit symptoms of III, IV, and VI nerve palsies. We hereby report a rare case of aseptic cavernous sinus embolism developed in a 75-year-old male with primary lung cancer who presented with binocular diplopia due to unilateral third and sixth cranial nerve palsies with pupil-sparing. The possibility of cavernous sinus cancer embolus should be considered if the routine examination excluded metastases, infiltration, carcinomatous meningitis, or the paraneoplastic process. 18F-FDG PET imaging may provide a promising diagnostic modality for the diagnosis of cancer embolus.

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Post-traumatic carotid-cavernous fistula with bilateral proptosis simulating cavernous sinus thrombosis

Cited by 6 publications

References 9 publications

CT angiogram findings in carotid-cavernous fistulas: stratification of imaging features to help radiologists avoid misdiagnosis

CT angiogram findings in carotid-cavernous fistulas: stratification of imaging features to help radiologists avoid misdiagnosis

Stick a Needle in My Eye: A Case Report of Penetrating Needlefish Injury Causing Cavernous Sinus Thrombosis and Carotid Cavernous Fistula

Case report: 18F-FDG PET confirmed pupil-sparing third nerve palsy heralding aseptic cavernous sinus embolism in patient with chest malignancy

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