Abstract
Carotid cavernous fistulae (CCF) are defined as abnormal connections between the carotid circulation and cavernous sinus. CCFs can be categorized as being direct or indirect. Direct CCFs are usually associated with trauma, whereas indirect CCFs are associated with revascularization following cavernous sinus thrombosis. We present a case of a 53-year-old male who presented with tinnitus, proptosis, conjunctivitis, and blurry vision. The patient had a recent endovascular transvenous embolization that was only partially successful, with a residual carotid cavernous fistula draining to the left superior ophthalmic vein and multiple cortical veins. A physical examination of the patient showed elevated intraocular pressures bilaterally. The patient had a high-flow indirect carotid cavernous fistula with bilateral superior ophthalmic vein (SOV) and retrograde cortical vein drainage. The SOV was punctured with a micropuncture needle and was used to successfully gain access to the cavernous sinus. Multiple coils were placed in the posterior aspect of the sinus until there was complete occlusion of venous flow. Coils were packed up to the posterior aspect of the orbit near the junction of the cavernous sinus with the SOV, and the embolization was successful. Indirect CCFs have gradual onset and are usually low-flow. Low-flow CCFs might improve with medical management.Some CCFs may cause ocular manifestations and can be symptomatically managed with prism therapy or ocular patching for diplopia, lubrication for keratopathy, or topical agents for elevated intraocular pressures. However, patients presenting with persistent ocular morbidity may require surgical or endovascular intervention.
Highlights
Carotid cavernous fistulae (CCFs) are abnormal communications between the internal or external carotid arteries and the cavernous sinus
We present the case of a male with an indirect CCF and prior subtotal coil embolization of the cavernous sinus, who required definitive treatment with a superior orbital vein (SOV) cut-down for additional embolization
A recently attempted endovascular transvenous embolization was only partially successful with residual carotid cavernous fistula draining to the left SOV and multiple cortical veins (Figure 5)
Summary
Carotid cavernous fistulae (CCFs) are abnormal communications between the internal or external carotid arteries and the cavernous sinus. Most CCFs are direct communications between the internal carotid artery (ICA) and the cavernous sinus and present with ocular symptoms due to venous hypertension [1,2]. We present the case of a male with an indirect CCF and prior subtotal coil embolization of the cavernous sinus, who required definitive treatment with a superior orbital vein (SOV) cut-down for additional embolization. An initial intracranial magnetic resonance angiogram (MRA) revealed flow-related arterial signals in the left more than right cavernous sinuses (Figure 1). A recently attempted endovascular transvenous embolization was only partially successful with residual carotid cavernous fistula draining to the left SOV and multiple cortical veins (Figure 5). The initial partial embolization required transvenous access through the right facial vein into the right SOV and across the circular sinus into the left cavernous sinus. A follow-up four-vessel angiogram was performed five months after the operation, which showed no recurrent fistula
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