Dural Carotid-cavernous Fistula Research Articles

Inferior Ophthalmic Vein-Dominant Dural Cavernous Fistula Embolization via Combined Orbitotomy and Direct Puncture of Inferior Ophthalmic Vein: A Case Report and Literature Review.

Dural carotid-cavernous fistulas (DCF) typically drain into the superior ophthalmic vein. Predominant involvement of the inferior ophthalmic vein (IOV) is rare, with only 4 documented cases in the literature. Here, the authors describe a case of a 51-year-old man who presented with acute left-sided proptosis, dysmotility, and vision loss and was found to have an IOV-dominant type D dural carotid-cavernous fistulas. The fistula could not be embolized by transfemoral endovascular access or orbitotomy alone and was ultimately managed with combined orbitotomy and direct IOV puncture. All previous reports of IOV-dominant dural carotid-cavernous fistulas in the literature were similarly inaccessible via the transfemoral approach. This case highlights the challenges of IOV cutdown and proposes an alternative management strategy. When IOV cutdown is precluded by the fragile, collapsed, or deep nature of the vessel, conversion to percutaneous IOV puncture may offer a safe and effective approach and mitigate the risks of direct puncture alone.

Intraorbital Arteriovenous Fistulas: Case Series and Systematic Review.

Intraorbital arteriovenous fistulas (AVFs) are an extremely rare subtype of intracranial fistula with ophthalmic symptoms similar to cavernous sinus dural AVFs or carotid cavernous fistulas but worse visual outcomes. Here, we present a case series and thorough systematic review on intraorbital AVFs to demonstrate treatment modalities and address this rare type of AVF. We conducted a retrospective study at a single center, in which we identified all cases of intraorbital AVFs that occurred between 2002 and 2022. We collected and analyzed data on demographics, fistula characteristics, treatment methods, clinical outcomes, and fistula closure. In addition, we conducted a systematic review of intraorbital AVFs. Seven cases in our center and 41 cases of intraorbital AVFs reported in the 35 articles were identified. At our center, transarterial embolization (TAE) (42.9%) alone resulted in immediate complete occlusion in 3 cases. Transvenous embolization (14.3%) resulted in one case of immediate complete occlusion. In 2 cases, surgery (28.6%) resulted in immediate complete occlusion. In one case, conservative treatment (14.3%) was used, and the fistula was eventually spontaneously occluded. Immediate complete occlusion rate was 85.7%. One blindness occurred (14.3%). In the literature reported, 3 cases (60%) of retinal artery occlusion were reported when performing TAE via the ophthalmic artery. Two fistulas recurred as reported. In 33 (80.5%) patients, the fistula was finally completely occluded. TAE via the ophthalmic artery carries a high risk of blindness and a low cure rate. Transvenous techniques such as conventional transvenous routes, surgical exposure, or direct puncture of the drainage vein have been used as the first line of treatment for intraorbital AVFs.

Direct and Dural Carotid Cavernous Sinus Fistulas: Comparison of Clinical Characteristics.

To compare the clinical characteristics of patients with direct and dural carotid cavernous sinus fistulas (CCFs). The medical records of 60 patients diagnosed with CCFs were retrospectively reviewed. The collected data included demographic characteristics, clinical findings, and ocular manifestation. The clinical characteristics of the direct and the dural CCFs were compared on head-to-head basis. Logistic regression analysis was used to demonstrate the direction and magnitude of the difference and reported as odds ratio with its 95% confidence interval. There were 28 patients (46.67%) with direct CCFs, and 32 patients (53.33%) with dural CCFs. Patients with direct CCF were mostly male (p=0.023), younger age (p<0.001), had history of trauma (p<0.001), and more visual impairment at presentation (p=0.025), when compared to those with dural CCFs. In addition, patients with direct CCF had significantly more chemosis (p=0.005), proptosis (p=0.042), bruit (p<0.001) and dilated retinal vessels (p=0.008) than those with dural CCF. Thirty patients (50%) had increased intraocular pressure (IOP). Mean IOP of the affected eyes was significantly higher than the unaffected eyes (p<0.0001). In patients with normal IOP, mean IOP of the affected eyes was also higher than the unaffected eyes (p=0.0027). Patients with direct CCF were younger age, associated with trauma, and more visual impairment at presentation. Chemosis, proptosis, bruit and dilated retinal vessels were detected more in the direct CCF than the dural CCF. Despite normal IOP, affected eyes had significantly higher IOP than the unaffected eyes. Information on these clinical characteristics may be helpful in discrimination of the direct type, which is more urgent for further investigation and treatment.

Bilateral Posterior Ischemic Optic Neuropathy Due to Bilateral Anterior-Drainage Dural Carotid-Cavernous Fistulas: A Case Report

To report a case of bilateral posterior ischemic optic neuropathy (PION) due to bilateral anterior-drainage dural carotid-cavernous fistulas (CCFs). We report on a 62-year-old woman with a history of poorly controlled hypertension who presented with sudden bilateral visual loss and headache for 5 days. She denied a history of head trauma. On examination, her visual acuities were no light perception (NLP) with fixed pupils in both eyes. The ocular motility of both eyes was limited in all directions. Both eyelids were difficult to open. Anterior segment examination revealed bilateral chemosis and episcleral corkscrew vessels. Intraocular pressures were 45 and 48 mmHg in her right and left eyes, respectively. Gonioscopy revealed blood in Schlemm's canal at the nasal angle of the right eye. Fundus examination showed slightly dilated and tortuous retinal veins with normal-appearing optic discs in both eyes. The cup-to-disc ratios were 0.3 bilaterally. Other neurological examinations were unremarkable. Magnetic resonance imaging demonstrated dilation of the bilateral superior ophthalmic veins (SOVs), and marked orbital and periorbital congestion bilaterally. However, there was no compression or stretching of the bilateral optic nerves. Diffusion restriction on diffusion-weighted imaging, with corresponding reduced apparent diffusion coefficient, in the entire bilateral orbital segment of the optic nerves was revealed, consistent with bilateral PION. Magnetic resonance angiography revealed arterialization of the bilateral cavernous sinuses and SOVs. Cerebral angiography confirmed the diagnosis of bilateral anterior-drainage dural CCFs. Treatment with transvenous coil embolization was successful. Three months after embolization, ophthalmic examination demonstrated progressive improvement of aforementioned ophthalmic signs; however, her visual acuities remained NLP in both eyes. To our knowledge, this is the first reported case of bilateral PION due to bilateral anterior-drainage dural CCFs. In spite of its rarity, PION should be considered as a severe, irreversible ophthalmic complication of anterior-drainage dural CCF.

Spontaneous Dural Carotid-Cavernous Fistula Treated with Microcoil Insertion

This report includes a case of a 65-year-old woman presenting with a spontaneous dural carotid-cavernous fistula. Biomicroscopic examination of the anterior segment showed significant conjunctival chemosis, dilatation of the episcleral vessels, narrow anterior chamber, and a proptosis of the right eye, whereas the fellow eye was unremarkable. Retinal examination revealed an impaired arteriovenous ratio (A/V) from 1–4 to 1–2 and two extensive cotton exudates. An ultrasound scan (US) demonstrated congestion of the upper ophthalmic vein. Selective brain angiography through right femoral catheterization revealed a dural fistula of the wall of the cavernous right sinus. The patient underwent surgery on the superior ophthalmic vein and insertion of a micro-catheter in the cavernous sinus under CT guidance. Furthermore, a trans-femoral catheter was placed in the carotid artery on the same side as the fistula to allow arteriographic controls after micro coil positioning and embolization. Angiographic follow-up immediately after positioning the coils showed the occluded fistula and a regular flow circulation between the internal and the external carotid arteries. After treatment, the patient presented a complete resolution of symptoms. Conservative management is effective and safe in treating patients with carotid-cavernous fistula and mild clinical features because of a good chance of spontaneous or secondary thrombosis after arteriographic occlusion.

Gamma Knife Radiosurgery for Indirect Dural Carotid-Cavernous Fistula: Long-Term Ophthalmological Outcome.

Objective: The leading treatment option for dural carotid–cavernous sinus fistula is an endovascular approach with immediate improvement. Alternatively, radiosurgery is a slow response for obliterating the fistula and poses a radiation risk to the optic apparatus and the associated cranial nerves and blood vessels. In this study, we retrieved cases from a prospective database to assess the ophthalmological outcomes and complications in treating dural carotid cavernous sinus fistula with gamma knife radiosurgery (GKRS). Material and Methods: We retrieved a total of 65 cases of carotid cavernous sinus fistula treated with GKRS with margin dose of 18–20 Gy from 2003 to 2018 and reviewed the ophthalmological records required for our assessment. Results: The mean target volume was 2 ± 1.43 cc. The onset of symptom alleviated after GKRS was 3.71 ± 7.68 months. There were two cases with residual chemosis, two with cataract, two with infarction, one with transient optic neuropathy, and four with residual cranial nerve palsy, but none with glaucoma or dry eyes. In MRA analysis, total obliteration of the fistula was noted in 64 cases with no detectable ICA stenosis nor cavernous sinus thrombosis. In the Cox regression analysis, post-GKRS residual cranial nerve palsy was highly correlated to targeted volume (p < 0.05) and age (p < 0.05). The occurrence of post-GKRS cataract was related to the initial symptom of chemosis (p < 0.05). Conclusion: GKRS for carotid cavernous sinus fistula offers a high obliteration rate and preserves the cavernous sinus vascular structure while conferring a low risk of treatment complications such as adverse radiation risk to the optic apparatus and adjacent cranial nerves.

Non-invasive angiographic analysis of dural carotid cavernous fistula using time-of-flight MR angiography and silent MR angiography: a comparative study.

A non-invasive, reliable imaging modality that characterizes cavernous sinus dural arteriovenous fistula (CSDAVF) is beneficial for diagnosis and to assess resolution on follow-up. To assess the utility of 3D time-of-flight (TOF) and silent magnetic resonance angiography (MRA) for evaluation of CSDAVF from an endovascular perspective. This prospective study included 37 patients with CSDAVF, who were subjected to digital subtraction angiography (DSA) and 3-T MR imaging with 3D TOF and silent MRA. The main arterial feeders, fistula site, and venous drainage pattern were evaluated, and the results were compared with DSA findings. The diagnostic confidence scores were also recorded using a 4-point Likert scale. Silent MRA correlated better for shunt site localization and angiographic classification (86% vs. 75% and 83% vs. 75%, respectively) compared to TOF MRA. The proportion of arterial feeders detected was marginally significant for silent MRA over TOF MRA sequences (92.8% vs. 89.5%; P=0.048), though for veins both were comparable. Sensitivity of silent MRA was higher for identification of cortical venous reflux (CVR) (90.9% vs. 81.8%) and deep venous drainage (82.4% vs. 64.7%), while specificity was >90% for both modalities. The overall diagnostic confidence score fared better for silent MRA for venous assessment (P < 0.001) as well as fistula point identification (P < 0.001), while no significant difference was evident with TOF MRA for arterial feeders (P=0.06). Various angiographic components of CSDAVF could be identified and delineated by 3D TOF and silent MRA, though silent MRA was superior for overall diagnostic assessment.

Клинический случай эндоваскулярного выключения дурального каротидно-кавернозного соустья трансвенозным трансорбитальным доступом

Представлен клинический случай эндоваскулярного выключения дурального каротидно-кавернозного соустья (ККС) трансвенозным трансорбитальным доступом. ККС — сложная патология сосудов головного мозга, при которой происходит формирование аномального шунтирования артериальной крови в кавернозный синус. Повышение давления в венозном синусе до уровня, который превышает венозное давление и достигает артериального давления, приводит к застойным явлениям в структурах, от которых оттекает венозная кровь в кавернозный синус в норме. Первый симптом заболевания — пульсирующий шум в височной области, наблюдается у большинства больных с ККС. Независимо от источника кровоснабжения ККС офтальмологическая симптоматика представлена признаками нарушения венозного оттока от глаза и орбиты. В клинической картине заболевания преобладает офтальмологическая симптоматика: экзофтальм, застойная инъекция глазного яблока, отек век, хемоз, глазодвигательные нарушения, офтальмогипертензия. Прогноз спонтанного течения заболевания при ККС неблагоприятен. Выздоровление происходит в 5–10 % случаев, летальность до 15 % от внутричерепного кровотечения, 50–60 % больных инвалидизированы вследствие потери зрения и психических нарушений. Основным методом лечения больных с ККС является эндоваскулярное выключение соустья из кровотока при помощи разных методов: баллон-катетеров, спиралей, использования жидких тромбирующих веществ. Венозный подход проводят через внутреннюю яремную вену и нижний каменистый синус (НКС). В случае тромбированного НКС катетеризация не всегда возможна. В связи с этим выполнение прямой хирургической пункции верхней глазной вены может быть методом выбора. Представленный клинический случай демонстрирует разобщение соустья путем имплантации спиралей трансвенозным трансорбитальным доступом через верхнюю глазную вену при невозможности проведения традиционного эндоваскулярного трансвенозного подхода через внутреннюю яремную вену и НКС. При проведении контрольной церебральной ангиографии, через 3 месяца, признаков патологического кровотока в области кавернозного синуса не выявлено. Клинический случай свидетельствует о важности ранней диагностики для своевременного выключения соустья из кровотока с целью сохранения функции зрения. Применение трансвенозного доступа через верхнюю глазную вену выполнено впервые в Украине.

Dural carotid-cavernous fistulas: our experience with endovascular management

BackgroundIndirect carotid-cavernous fistulas (CCF) are dural arteriovenous fistula of the cavernous sinus and generally present with ocular symptoms. High index of clinical suspicion and radiological work up is required for diagnosis, and treatment is primarily endovascular embolization. We present our experience in diagnosis and management of indirect CCF along with technical evolution to perform embolization and different vascular accesses for difficult anatomy.ResultsAmong a total of 20 indirect CCF cases who were treated with embolization in our department from 2013 to 2020, five (25%) were type C and 15 (75%) were type D. Seven were treated with trans-arterial access only, 11 were treated by transvenous access only, and two were treated by taking both transvenous and trans-arterial access. No recurrence was seen in angiographically cured patients. Out of seven patients who suffered various grades of visual deficit, five recovered completely and two had fixed visual deficit. Third and sixth cranial nerve palsy persisted in two patients even after CCF embolization.ConclusionIndirect CCF is a treatable cause of troublesome ocular symptoms. Endovascular embolization is preferred treatment with excellent short- and long-term outcome. The embolization becomes difficult and challenging in cases where the conventional vascular access to the cavernous sinus is occluded.

Dural carotid cavernous sinus fistula: outcome after endovascular treatment or conservative management

PurposeTo analyze the efficacy of endovascular treatment and conservative management in patients with dural arteriovenous sinus fistula.MethodsRetrospective and observational study, including patients with dural carotid cavernous fistula followed at Ophthalmology and Neuroradiology departments of Hospital Santa Maria – Lisbon between 1991 and 2019. Patient demographics, risk factors, symptoms, etiology, angiographic findings and clinic outcome were studied.ResultsNineteen patients were included. 53% were female and mean age at diagnosis was 64 years (range from 10 to 78). Atherosclerosis risk factors were identified: hypertension (79%), diabetes (21%) and hyperlipidemia (21%). Ocular symptoms were the only presentation of the disease, with proptosis and hyperemia being the main clinical signs. Bilateral fistula was found in 16%. Spontaneous fistula occurred in 81% and trauma history was identified in 19%. %. According to Barrow angiographic classification, 11% were grade B, 21% C and 58% D. Endovascular treatment by transvenous/transarterial embolization was performed in 79% (n = 15), 73% with complete exclusion in a mean of 8.6 ± 17.4 months. The mean follow‐up was 4.0 ± 3.1 years after procedures. Conservative management was performed in 21% (n = 4) and the last follow‐up was 3.5 ± 5.0 years. In both groups, most patients (65–75%) showed symptoms and ophthalmologic examination improvement. After endovascular treatment, visual acuity was maintained (0.7 ± 0.4), and there was intraocular pressure reduction (25.1 ± 6.5 to 15.0 ± 2.3 mmHg). In patients with conservative management, there was no change in visual acuity (0.4 ± 0.5) and intraocular pressure decreased with medication (29.3 ± 9.5 to 19.3 ± 9.2 mmHg). Secondary ocular hypertension (25%) was a long‐term complication of carotid cavernous sinus fistulas.ConclusionsOcular symptoms are the most frequent presentation of dural carotid cavernous fistula, with ocular hypertension as the commonest complication. In less symptomatic patients, the risks and benefits of endovascular treatment should be considered, as conservative treatment may be an option.

Superficial middle temporal vein as a pivotal route to embolize dural carotid–cavernous fistulas

Dural carotid–cavernous fistulas (DCCF) are located in the cavernous sinus wall involving the arterial feeders from the external and internal carotid arteries. The venous route usually passes through the internal jugular vein and inferior petrosal sinus (IPS) up to the pathologic shunts of the cavernous sinus. In cases of a thrombosed IPS, catheterization is not always possible because of the obstruction. Here, we report eight cases of DCCF treated with endovascular transvenous embolization via the superficial middle temporal vein (SMTV). A retrospective study involving eight patients with DCCF treated with transvenous embolization via SMTV was performed. In six patients, IPS was thrombosed. In one patient, IPS was patent, but we could not catheterize the internal jugular vein. In the other patient, because of the compartmentalization of the cavernous sinus, we could not access the anterior part of the cavernous sinus via IPS. Therefore, we performed the embolization via SMTV to occlude the shunts of the anterior part of the cavernous sinus.In all eight cases, navigating through the tortuous junction of the angular vein and superior ophthalmic vein (SOV) was possible. After transvenous catheterization of the cavernous sinus via SMTV, placement of coils resulted in complete occlusion of DCCF with clinical improvement in all eight patients. In the endovascular treatment of DCCF, the transfemoral approach via SMTV provides a pivotal route alternative to other transvenous routes. In patients with dilated SOV, catheterization of the cavernous sinus via SMTV is usually successful.

Patient reported long-term outcome after endovascular therapy of indirect dural carotid cavernous fistulas.

PurposePatient-reported long-term follow-up after endovascular treatment of indirect carotid cavernous fistulas is important, but rarely addressed in literature. We report on this issue with a special focus on the patient’s view and its impact on the indication evaluation process.MethodsWe retrospectively reviewed the records of all patients (n = 33) with a minimum follow-up interval of at least 36 and up to 166 months after endovascular treatment of an indirect carotid cavernous fistula (Barrow B-D) at our institution (treated from 01/2003 to 06/2015). We determined treatment details including primary therapy success and complication rate and quote the patient’s subjective perception of the long-term treatment success using a standardized interview form.ResultsAs a primary result the fistula was completely occluded in 25/33 cases (76%), while a downgrading was achieved in 8/33 (24%) of the cases. Secondary occlusion was observed in three out of eight patients (38%). In the long-term interview (response rate: 91%, median follow-up interval: 114 months) 87% of the patients reported high satisfaction with the long-term therapy result. Endovascular treatment achieved a sustainable relief from all eye-related symptoms in 89% and from pulsatile tinnitus in 57% of the cases.ConclusionsIn addition to good results in terms of angiographic and clinical cure, endovascular treatment is also perceived as beneficial by most of the patients. This is another important argument in favor of an endovascular treatment.

Delayed Diagnosis of Dural Carotid Cavernous Fistula in a Patient with Open-Angle Glaucoma

Delayed Diagnosis of Dural Carotid Cavernous Fistula in a Patient with Open-Angle Glaucoma

Endovascular therapy of direct dural carotid cavernous fistulas - A therapy assessment study including long-term follow-up patient interviews.

PurposeEndovascular embolization nowadays is a well-established treatment option for direct carotid cavernous fistulas (dCCF, Barrow Type A). There are many publications on the complication and success rates of this method. However, little is known on the patients´ opinion on the treatment result after several years. We report on this issue also including the “pioneer patients” treated almost two decades ago.MethodsWe retrospectively reviewed the records of all patient (n = 25) with a more than 24 months follow-up interval after endovascular treatment of a dCCF at our institution from 01/1999 to 08/2018. We determined primary therapy success, complication rate, state of the fistula in the last imaging follow-up and quoted the patient’s subjective perception of the long-term treatment success using a standardized interview form.ResultsOcclusion rate in the last imaging follow up was 96% (24/25) with a complication rate of 8% (2/25). The response rate on our interview request was 96% (24/25) with a rate of considered feedback of 84% (21/25 patients). Duration of our observation interval for the patient reported outcome was 143 months / 11 years (median, range: 35–226 m / 2–18 y). Most of them (21/25, 84%) felt they benefited from the treatment.ConclusionsEndovascular supply of dCCF is a highly effective treatment method leading to a sustainable therapy success with long-lasting stable subjective benefit even to our “pioneer patients” treated almost two decades ago.

Central retinal vein occlusion complicating spontaneous dural carotid-cavernous fistula after phacoemulsification.

In this report, we are presenting a case of a 49-year-old female complaining of defective vision in the left eye. The main complaints were: pain, redness, mild proptosis, and high intraocular pressure. She had a history of uneventful phacoemulsification surgery 3 months prior to presenting to us. Investigations revealed a macular edema caused by central retinal vein occlusion and computed tomography angiography showed an early opacified left cavernous sinus with a dilated superior ophthalmic vein along with a fistula between the meningeal branches of the carotid arteries and the cavernous sinus. Improvement of ocular symptoms was achieved after endovascular treatment by transarterial and transvenous embolization.

Imaging-Guided Superior Ophthalmic Vein Access for Embolization of Dural Carotid Cavernous Fistulas: Report of 20 Cases and Review of the Literature.

Dural carotid cavernous fistulas are usually treated via a transvenous approach through the inferior petrosal sinus. Surgical exposure and direct access to the superior ophthalmic vein have been previously described in situations in which conventional transvenous access, including the inferior petrosal sinus, is not possible. In this retrospective study of 20 patients, we report our results of imaging-guided percutaneous superior ophthalmic vein access in dural carotid cavernous fistula treatment. The superior ophthalmic vein was accessed after direct percutaneous puncture under sonographic guidance in 16 patients and biplane roadmap guidance in 4 patients. In all 20 patients, it was possible to access the superior ophthalmic vein and cure the dural carotid cavernous fistula. Two patients developed a retrobulbar hematoma after postseptal puncture, which required emergency lateral canthothomy. In our experience, direct imaging-guided percutaneous superior ophthalmic vein access is a safe alternative approach for treatment in situations in which conventional transvenous approaches are not possible.

The routes for embolization of dural carotid cavernous fistulas when the endovascular approach is indicated as a first-line strategy.

Multiple ways to access the dural carotid cavernous fistula have been described. The aim of the present study was to assess the results of embolization of a dural carotid cavernous fistula via different routes using endovascular accesses as a first-line strategy. A retrospective data analysis of a consecutive series of 63 patients presenting with dural carotid cavernous fistula was performed. The dural carotid cavernous fistula was accessed by an endovascular approach in 58 patients (92.1%) and by direct puncture in five patients (7.9%). The inferior petrosal sinus was the main route accessed (65%). A recanalization of an occluded inferior petrosal sinus was obtained in 20.6% of cases. The access via either facial ophthalmic veins or the superior petrosal sinus was obtained in 20.6% and 3.1% of cases, respectively. Complete angiographic occlusion of a dural carotid cavernous fistula immediately after treatment was achieved in 53 patients (84.1%), whereas 10 patients (15.9%) displayed a partial occlusion. Treatment-related complications were observed in two patients (3.2%). In this study, the endovascular approach allowed dural carotid cavernous fistula embolization in most patients. The inferior petrosal sinus, even when thrombosed, was the main route used to access the dural carotid cavernous fistula, followed by the facial vein, direct cavernous sinus puncture, and the superior petrosal sinus.

Transarterial Embolization of an Indirect Carotid- Cavernous Fistula with N-Butyl Cyanoacrylate

Carotid-cavernous fistulas are vascular shunts that allow blood to flow from the carotid artery into the cavernous sinus. Some fistulas are characterized by a direct connection between the cavernous segment of the internal carotid artery and the cavernous sinus. Other carotid-cavernous fistulas are dural, consisting of a communication between the cavernous sinus and one or more meningeal branches of the internal carotid artery, the external carotid artery, or both. Endovascular management is the treatment modality of choice in these cases. We report the use of N-butyl cyanoacrylate in a successful transarterial embolization of a dural carotid-cavernous fistula fed by arterial branches of the internal -and mainly- external carotid arteries (Barrow type D).

Choroidal thickening in a case of carotid cavernous fistula

ABSTRACTA 47-year-old woman was diagnosed with dural carotid cavernous fistula (CCF) in her right eye (RE). Scans of the choroid using Spectralis optic coherence tomography (OCT) demonstrated significant asymmetry in subfoveal choroidal thickness (RE 451 μm, left eye (LE) 367 μm). This asymmetry disappeared after the fistula was embolizated through the ophthalmic artery (RE 341 μm; LE 340 μm). This case suggests that OCT should be considered as an ancillary test in the diagnosis of CCF.

Isolated abducens palsy of advanced age: a rare presentation of dural carotid cavernous fistula: a case report

Abducens palsy is the most common isolated cranial nerve palsy due to its long peripheral course. Multiple anatomical relationships, particularly within the cavernous sinus and orbita, make the nerve vulnerable. 67 year-old female patient was admitted with worsened headache and lateral gaze restriction of the left eye, which appeared recently. She had no prior history of trauma. Prominent appearance of the left cavernous sinus on cranial magnetic resonance imaging, raised the need of digital substraction angiography which revealed the presence of bilateral type D dural arteriovenous fistula of cavernous sinuses. Cavernous sinus pathologies, which are usually known to manifest with multiple ocular motor palsies because of the close relationship between 3rd, 4th and 6th nerves inside, might rarely present with isolated abducens palsy. The clinician should pay particular attention to headache in such kind of patients and dural carotid-cavernous fistula should be taken into account, even in the absence of previous trauma history.