Ophthalmological presentation of carotid cavernous fistulas: case series

Abstract

AbstractPurposeTo describe the clinical presentation of carotid cavernous fistulas (CCFs) managed in Egas Moniz Hospital between January 2010 and September 2020.MethodsPatients presenting with orbital congestive signs and symptoms with a diagnosis of CCF confirmed by digital subtraction angiography and ophthalmological evaluation were included retrospectively. Clinical presentation and angiographic findings were collected, and a descriptive study was performed.ResultsTen patients were identified, 7 of which female, with an average age of 62.7 years old. All of our patients presented with ophthalmological complaints. The most frequently seen signs/symptoms were red eye (n = 8), increased intra‐ocular pressure (IOP) (n = 8) and ophthalmoparesis with diplopia (n = 7). Regarding the latter, 5 patients had paresis of the abducens nerve, 1 had a third nerve palsy and another had both. Proptosis and chemosis were observed in 5 and 4 patients, respectively. Tinnitus, fundus abnormalities and decreased visual acuity were reported by 3 patients. One patient presented with headache. In respect to the angiographic classification, 2 were direct and 6 indirect. One case was not classified and the other case refers to an intra‐clival Cognard type IV arteriovenous fistula that drains to the cavernous sinus and therefore closely resembling a CCF. Two patients were managed conservatively, while the remainder were submitted to endovascular procedures. After treatment, the most frequent persistent signs/symptoms were increased IOP (n = 7) and ophthalmoparesis with diplopia (n = 5).ConclusionsCCFs are rare and difficult to diagnose. Direct CCFs tend to have a more severe, acute onset presentation while indirect CCFs are associated with a more gradual onset and chronic course. In both, anterior and inferior drainages are the most common. Clinical presentation can be varied and nonspecific, however, patients commonly present with ophthalmological manifestations.