Traumatic carotid cavernous fistula.

Abstract

A 46-year-old man presented with a closed head injury from a motor vehicle crash. Six days after the injury, he complained of pain in his right eye and swelling of the right orbit. Physical examination revealed 6-mm proptosis associated with chemosis. A bruit was audible over the right orbit. No cranial nerves or extremity neurological deficits were evident. Cerebral angiography showed a posttraumatic carotid cavernous fistula (CCF) (A, bottom arrow) with direct opacification of the cavernous sinus and early filling of the superior ophthalmic veins (A, top arrow). Subsequently, the patient underwent transarterial coil embolization (B, arrow). The orbital bruit disappeared and chemosis rapidly decreased. He made uneventful recovery and remained without focal neurologic deficit. CCF is a communication between the cavernous portion of the carotid artery and the venous plexus of the cavernous sinus. In contrast to the spontaneous variety, post-traumatic CCF is usually from direct shunting between the carotid artery and the cavernous sinus with high flow and pressure. Although CCF can be caused by penetrating cranial injuries, severe blunt trauma is the most common mechanism. Fistulas usually appear within a few weeks after the injury with symptoms and signs related to increased venous pressure transmitted through the valveless ophthalmic veins. Orbital bruit is invariably audible and pulsating exophthalmos with chemosis are often present. With post-traumatic CCF, cerebral angiography reveals direct opacification of an enlarged cavernous sinus, early filling of ophthalmic veins, and diminished opacification of the distal arterial system (A). Complications of CCF include cranial (most commonly the sixth) nerve palsy, progressive visual impairment, and subarachnoid hemorrhage. The goal of management of CCF is occlusion of the fistula while maintaining carotid artery patency. Although surgical treatment was previously advocated, several endovascular procedures have recently been used to achieve this goal. Because percutaneous embolization of CCF effects occlusion of the fistula and carries low morbidity and mortality, it is currently considered the treatment of choice.