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Journal Reading

Journal Reading. VS 孫銘希 / PGY R1 呂威揚 2007 / 01 / 11. Carotid-cavernous Fistula. Overview Traumatic Carotid-Cavernous Fistula: Pathophysiology and Treatment (THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 14, NUMBER 2 March 2003).

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Journal Reading

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  1. Journal Reading VS孫銘希 / PGY R1 呂威揚 2007 / 01 / 11

  2. Carotid-cavernous Fistula • Overview • Traumatic Carotid-Cavernous Fistula: Pathophysiology and Treatment (THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 14, NUMBER 2 March 2003)

  3. Specific type of dural arteriovenous fistula characterized by abnormal arteriovenous shunting within the cavernous sinus • Abnormal communication between previously normal carotid artery and cavernous sinus • High-pressure arterial blood entering the low-pressure venous cavernous sinus

  4. Direct Carotid Cavernous Fistula • Arterial blood passes directly through a defect in the wall of intracavernous portion of ICA • Blood in vein becomes arterialized • Venous pressure increases • Arterial pressure and perfusion decreases • From trauma in 75% of all cases, spontaneous rupture of aneurysm or atherosclerotic artery in 25%

  5. Clinical features • Symptoms develop suddenly • Pulsating tinnitus as a “noise” inside the head. Pain may follow. • Ocular manifestations: ophthalmic venous hypertension and orbital venous congestion, proptosis, corneal exposure, chemosis and arterialization of episcleral veins.

  6. Indirect Carotid Cavernous Fistula • Fistulous connection is within the wall of the cavernous sinus • Tend to be low-flow • Small meningeal arteries supplying dural wall of cavernous sinus can rupture spontaneously, while ICA itself remains intact • Insidious onset, mild orbital congestion, proptosis, low or no bruit

  7. Radiological Evaluation of C-C Fistula • Angiography is the definitive diagnostic examination • CT and MRI may show • Enlarged superior ophthalmic vein • Enlarged muscles • Enlarged cavernous sinus with a convex shape to the lateral wall

  8. Treatment of C-C Fistula • Spontaneous closure occurs in up to 60% • Most are not life-threatening • Main indicators for treatment • Glaucoma • Diplopia • Intolerable bruit • Severe proptosis causing exposure keratopathy

  9. Traumatic Carotid-Cavernous Fistula:Pathophysiology and Treatment(THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 14, NUMBER 2 March 2003)

  10. Right and left cavernous sinuses

  11. The cavernous sinus essentially functions as a dural venous structure, receiving blood supply from the superior and inferior ophthalmic veins as well as from the sphenoparietal sinuses. • The venous architecture of the cavernous sinus is maintained by multiple communicating sinusoids, allowing the venous blood flow to be quite slow and of low pressure.

  12. CN III, IV, V1 and V2 are located on the lateral aspect of the sinus. CN VI, however, lies medially in the sinus and thus is not protected by the same dural influences.

  13. Classification and Incidence • The universally adopted classification system in the CCF literature is the schema developed by Barrow in 1985 based on angiographic studies.

  14. Type A (direct): shunt between the ICA and cavernous sinus ; usually associated with trauma (TCCF) and produce early signs and symptoms • Type B (indirect): shunt between the meningeal branches of the ICA and cavernous sinus • Type C (indirect): shunt between the meningeal branches of the ECA and cavernous sinus • Type D (indirect): shunt between the meningeal branches of the ICA, ECA, and cavernous sinus

  15. Direct CCF (Type A or TCCF) are high-flow shunts, which occurs three times as often as the indirect types. • Type A shunts are not only frequently associated with trauma, but they also predominantly occur in men. • Indirect or dural CCF (Type B,C, and D) are low-flow shunts and usually occur spontaneously. These indirect lesions are more common in the elderly and women, with an increased peak in incidence during pregnancy. • Most CCF are unilateral; bilateral cases account for 12% to 15% of the cases and are usually of the indirect variety.

  16. Clinical Presentation • The majority of the signs and symptoms of CCF are the result of shunting of blood between a high-flow and low-flow system. • The orbits, whose venous drainage travels to the cavernous sinuses through the superior and inferior ophthalmic veins, are the first structures to manifest the symptoms of this reversed blood flow. • Onset of symptoms may occur within hours after injury (direct) or may be delayed for months (indirect).

  17. Patients often complain of a swollen red eye, orbital pain, loud buzzing and swishing sounds, diplopia, headache and progressive vision loss. • Common signs of CCF include proptosis, temporal / orbitalbruit, chemosis, extraocular palsy (especially of CN VI, which is often the first CN to be affected), pulsating exophthalmos, ptosis, elevated IOP, anterior segment ischemia, papilledema, and optic nerve atrophy.

  18. Diagnosis and Evaluation • In addition to the common clinical symptoms, the only relevant clinical test confirming the diagnosis of CCF is that the bruit should cease with digital compression of the ipsilateral carotid artery in the neck. • Four-vessel digital subtraction cerebral angiography is the current gold standard in the diagnosis of CCF.

  19. Unilateral CCF

  20. CT with contrast is also quite useful because it can depict any bony fractures / spicules around the cavernous sinus as well as outlining engorged superior ophthalmic veins, a common radiographic finding in CCF.

  21. Treatment • The spectrum of treatment modalities traditionally included ligation or trapping of the carotid artery, and balloon embolization combined with carotid artery ligation. • Endovascular detachable balloon occlusion of CCF introduced through a transfemoral access allows preservation of the distal aspect of the ICA, thereby reducing morbidity.  current standard therapy !!

  22. Some clinicians believe that unless urgent treatment is indicated (i.e., rapid loss of vision, progressive hemiplegia, herniation of cavernous sinus into the sphenoid sinus), a 6-week delay and a repeat angiogram may be prudent before intervention. • Successful embolization of CCF will result in immediate resolution of proptosis, chemosis, and bruits. Ophthalmoplegia and optic nerve dysfunction may take up to 4 months for resolution. • The overall mortality of CCF is low, with major ICH occurring in only 3% of the cases.

  23. Summary • A carotid cavernous fistula is a rare but potentially lethal condition. • Direct CCF usually results from trauma. • Patients typically present with proptosis, chemosis, and a bruit. • Angiography when p’t stable • Transarterial embolization

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