Visual impairment in high flow and low flow carotid cavernous fistula

Abstract

Our aim is to study the varied posterior segment manifestations, level of visual impairment (VI) and its causes in carotid cavernous fistula (CCF) patients. A retrospective study was done, wherein data was obtained from 48 digital subtraction angiogram (DSA) proven CCF patients. CCF was classified according to Barrow et al ., based on DSA into type A (high flow) and types B, C and D (low flow). High flow CCF was present in 8 (16.7%) and low flow CCF was present in 42 (83.3%). Compared to low flow group, patients in high flow group were younger and had a history of trauma (p < 0.05). Posterior segment findings ranged from familiar stasis retinopathy and optic neuropathy (both, glaucomatous and ischemic) to uncommon findings of central retinal artery occlusion, Terson syndrome and combined retinal and choroidal detachment. Retinal vein dilatation was the most common finding in both groups. The high flow CCF group had 6 (75%) patients that had VI. This was acute in 4 (50%) patients and delayed in 2 (25%). In the low flow group 10 (23.8%) of patients had delayed VI. The identification of “3 point sign” is a novel finding of this study, not described before. While none of three findings (disc hyperaemia, retinal vein dilatation and intra-retinal haemorrhage) in isolation were predictive of visual loss, but when present together results in visual loss. Posterior segment changes were varied, some are uncommon and can occur in various combinations. “3 point sign” must be identified at the earliest to prevent visual impairment. The incidence of VI in CCF patients is high.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas. Institutional Series, Systematic Review and Meta-Analysis

“…On the other hand, local pain, headache, pulsatile tinnitus and visual acuity reduction were less frequently reported; however, whether the first three may be relatively subjective symptoms, visual impairment and increase of the intraocular pressure reflect a condition of severe venous congestion observed in advanced cases [ 28 , 29 ].…”

“…a Arterial approach, b transvenous through inferior petrosal sinus approach, c transvenous through superior ophthalmic vein approach, d direct puncture of the cavernous sinus through the superior ophthalmic fissure 4/5, probably due to its inner course within the cavernous sinus, while a III and IV cranial nerves palsy overall in 1/5. On the other hand, local pain, headache, pulsatile tinnitus and visual acuity reduction were less frequently reported; however, whether the first three may be relatively subjective symptoms, visual impairment and increase of the intraocular pressure reflect a condition of severe venous congestion observed in advanced cases [28,29].…”

Carotid cavernous sinus fistula with central retinal artery occlusion: A case report

“…An increase in venous pressure can compromise retinal vein outflow and produces venous stasis retinopathy and CRVO. 6 Rarely, CCF may cause CRAO from a steal phenomenon in the cerebral vessels. In this case, cerebral angiography did not show significant decreased flow into the right middle cerebral artery territory.…”

Carotid-cavernous fistula: A case report

“…If it drains anteriorly by the superior ophthalmic vein, orbital symptoms like chemosis, proptosis can be observed, but if the drainage is posterior through the inferior or superior petrosal sinus, orbital symptoms and signs are usually absent [1,4]. Patients with low flow CCFs usually have mild signs and symptoms and may be misdiagnosed [5].…”