1 / 24

Carotid Cavernous Fistula

Carotid Cavernous Fistula. Laura S Gilmore, MD Department of Ophthalmology TTUHSC February 13, 2004 Discussant: Kenn Freedman, MD. Case Presentation. 26yo AAM s/p MVA CHI, L zygoma fracture Consulted for proptotic, red OS

psyche
Download Presentation

Carotid Cavernous Fistula

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Carotid Cavernous Fistula Laura S Gilmore, MD Department of Ophthalmology TTUHSC February 13, 2004 Discussant: Kenn Freedman, MD

  2. Case Presentation • 26yo AAM s/p MVA • CHI, L zygoma fracture • Consulted for proptotic, red OS • CT: proptosis OS. No basilar skull fracture. no retrobulbar hematoma, no superior ophthalmic vein enlargement, no ocular muscle enlargement

  3. Differential Diagnosis Cavernous Sinus Thrombosis • Retrobulbar Hematoma • Unrecognized intra-orbital FB, with possible cellulitis • Carotid Cavernous Sinus Fistula • Tumor

  4. Physical Exam • General: sedated, intubated • Lids: edematous, margins intact • Pupils: 2.5mm->2mm, 7->NR • Conj: chemosis, OS>OD; SCH OS • IOP: 16, 28 • Cornea 2+ edema OS, clear OD • + gross proptosis OS • + bruit OS on auscultation, no neck bruit • DFE: discs flat with sharp edges, vessels normal, retina flat OU

  5. MRI of CC Fistula

  6. Carotid Cavernous Fistula • Abnormal communication between previously normal carotid artery and cavernous sinus • Characterized as: -Direct vs. Indirect -High vs. Low Flow -Traumatic vs. Spontaneous

  7. Types of CC Fistula

  8. Mechanisms of CCSF • Trauma • Spontaneous causes: • rupture of intracavernous aneurysms • neurofibromatosis • atherosclerotic disease • collagen vascular disease • Iatrogenic

  9. 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

  10. Signs of Direct CCSF • Ptosis • Very red, chemotic conj • Increased IOP from increased episcleral venous pressure • Anterior segment ischemia in 20% • Corneal edema, cell/flare, iris atrophy, rubeosis, cataract • Proptosis is pulsatile • Bruit and thrill • Muscle palsies • Visual loss

  11. Etiologies of Direct CCSF • From trauma in 75% of all cases • Basal skull fracture tears ICA within cavernous sinus • Traumatic fistulae-high flow rates, sudden and dramatic onset of symptoms • Spontaneous rupture of aneurysm or atherosclerotic artery in 25% • Post-menopausal, hypertensive females • Lower flow rates, less severe symptoms

  12. Mechanisms of Traumatic CCSF • direct injury from basilar skull fracture • injury from torsion or stretching of the carotid siphon upon impact • impingement of the vessel on bony prominences

  13. 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 • Lesions may fluctuate, and may resolve spontaneously

  14. Clinical Presentation of CCSF • Ophthalmic consequences of CCSF are caused by compression and ischemia related to increased venous pressure and reduced arterial pressure • flow reversal leads to engorged ophthalmic veins causing proptosis, conjunctival injection, chemosis. • Patients complain of retro-orbital headache, or a bruit. Facial pain with V1 and V2 involvement

  15. Clinical Presentation of CCSF • Other manifestations: • congestion of the opposite orbit • diplopia • ptosis, mydriasis • corneal ulceration • loss of visual acuity • transient neurological deficits • subarachnoid hemorrhage

  16. Radiological Evaluation of CCSF • 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

  17. Treatment of CCSF • Most are not life-threatening • Only involved eye is at risk typically • Main indicators for treatment • Glaucoma • Diplopia • Intolerable bruit or HA • Severe proptosis causing exposure keratopathy • Spontaneous closure from thrombosis of cavernous sinus is unlikely (as in trauma, high-flow)

  18. Treatment of CCS Fistulas • 99% of treatment is done by interventional neuroradiologists • Intravascular approach-placement of thrombogenic materials, eg coils • Other therapies include: • carotid artery ligation • surgical exposure with clipping of the fistula

  19. Summary • Direct CCSF usually results from trauma • Patients typically present with proptosis, conjunctival injection, and a bruit • Angiography when pt stable • Transarterial embolization

More Related