Transient fourth nerve palsy preceding cervical myelopathy due to carotid-cavernous fistula

Carotid-cavernous fistulas (CCFs) are rare intracranial vascular malformations. Among the various classifications available, the most recently proposed highlights the strong correlation between venous drainage pattern and clinical presentation. We present the case of a woman in her 70s with a history of transient palsy of the fourth cranial nerve who presented with subacute cervical myelopathy, which was caused by a CCF with venous drainage into the peribulbar and perimedullary plexus.Given this atypical presentation of CCF and the diagnostic challenges it poses, we conducted a comprehensive PubMed search looking for CCFs presenting with cervical myelopathy and our results confirmed their rarity and allowed us to identify clinical elements that may help clinicians diagnose and manage this potentially treatable condition.

Clinical Presentation of Carotid-Cavernous Fistula and Outcomes of Endovascular Balloon Embolization

Objectives

To describe the clinical presentation of carotico-cavernous fistula (CCF) and outcomes of endovascular balloon embolization in a tertiary care center in a developing country.

Materials and Methods

This retrospective interventional case series included 18 patients who underwent endovascular balloon embolization from 2019 to 2022 at Lahore General Hospital in Lahore, Pakistan. The analyzed data consisted of age, gender, cause and type of CCF, clinical presentation, diagnostic technique used, intervention, and the results of two-month follow-up. Patients with incomplete records and coil embolization were excluded. Digital subtraction angiography was done in all cases followed by endo-arterial balloon embolization. Procedures were carried out under general anesthesia via femoral artery approach. A single balloon was sufficient to close the fistula in all cases.

Results

There were 18 patients who met the inclusion criteria. Sixteen patients had direct CCF, and the mean age of the patients was 27.2±12.6 years. The commonest cause of CCF was trauma, and the mean time of presentation after trauma was 7.89±7.19 months. The male-to-female ratio was 8:1. Preoperative visual acuity was worse than 6/60 in 8 patients, between 6/60 and 6/18 in 7 patients, and better than 6/18 in 3 patients. The mean intraocular pressure was 16.06±3.37 mmHg preoperatively and 14.83±3.49 mmHg postoperatively (p=0.005). Endovascular embolization was successful in 15 patients (83.3%). One patient developed epidural hematoma as a complication of the procedure, which was drained later. There was no mortality related with the procedure.

Conclusion

Balloon embolization via the femoral artery is an efficient technique in direct as well as indirect CCF. It is safe and simple with very good results if performed in a timely manner.

Evaluating the Incidence and Neuro-Ophthalmic Manifestations of Carotid-Cavernous Fistulas

BACKGROUND

To determine the incidence of carotid-cavernous fistula (CCF) and describe the neuro-ophthalmic manifestations and eventual clinical outcomes.

METHODS

This was a population-based, retrospective cohort study using the Rochester Epidemiology Project to identify patients aged 18 years or older residing in Olmsted County, MN, diagnosed with CCF from 1997 to 2019. The medical records were reviewed for ophthalmic signs and symptoms, including conjunctival chemosis, proptosis, orbital bruit, diplopia, ophthalmoplegia, orbital pain, ocular hypertension, and blurred vision. Also determined was the number of patients with CCF found incidentally on neuroimaging, without clinical manifestations.

RESULTS

Ten patients were diagnosed with a CCF between 1997 and 2019 with an overall incidence rate of 0.37 per 100,000 per year (95% CI 0.20-0.68). The median age was 50.5 years (range 23-74 years), 6 (60%) were female, and 9 were White and 1 patient was Korean. Three patients (30%) were asymptomatic and found incidentally on imaging that was obtained for unrelated reasons, and one patient's ocular details were unavailable because she passed away from severe head trauma. The following neuro-ophthalmologic or ocular manifestations were identified in the remaining 6 patients: chemosis/conjunctival injection (n = 6), cranial nerve (CN) VI palsy (n = 6), CN III palsy (n = 2), proptosis (n = 4), ocular/orbital pain (n = 3), audible orbital bruit (n = 2), ocular hypertension (n = 1), and blurred vision (n = 1). Of those patients with symptomatic CCFs, all underwent treatment except for one that spontaneously resolved. None of the patients suffered a stroke or cerebral hemorrhage. The 3 patients with incidentally discovered CCFs were asymptomatic and did not require treatment.

CONCLUSIONS

This is the first population-based study to show a low incidence rate of CCFs, supporting the notion that it is an uncommon condition. Neuro-ophthalmic manifestations are common, especially chemosis/conjunctival injection and CN VI palsy. Up to a third of patients with CCF can be asymptomatic and may be found incidentally on neuroimaging during the evaluation for unrelated symptoms.

High-flow carotid cavernous fistula and 'white eye': A rare and easily misdiagnosed presentation - A case report and literature review

The three classic symptoms of carotid cavernous fistula (CCF) are pulsating exophthalmos, bruit and conjunctival chemosis. Here, we present a clinical case of isolated abducens nerve palsy due to a high-flow CCF in an 84-year-old woman, without the typical congestive orbito-ocular features. It was a diagnostic challenge because, for patients older than 50 years with cardiovascular risk factors, ischaemic mononeuropathy is the most frequent aetiology. This case illustrates the least common type of CCF that can be easily misdiagnosed. Physicians should consider fistula as a possible diagnosis in a patient with isolated abducens nerve palsy even without the classic triad.

Pressure-Lowering Effect of Interventional Fistula Occlusion in Secondary Glaucoma due to Orbital Draining Intracerebral Fistulae

BACKGROUND

Carotid cavernous sinus fistulas (CSCF) are pathological connections of the internal and/or external carotid artery (and/or its branches) to the cavernous sinus. Ophthalmological symptoms and problems occur particularly when drainage is via the superior ophthalmic vein.

MATERIAL AND METHODS

Seven eyes of six patients with a high-grade suspicion of CSCF were included in this retrospective monocentric study. Digital subtraction angiography (DSA) was performed in the included patients, where an interventional fistula closure was performed in the case of CSCF. Four of the six patients received a pre- and post-interventional day-night intraocular pressure profile. Furthermore, medical history, symptoms, visual acuity, slit lamp microscopic findings, and DSA findings were evaluated.

RESULTS

The most common symptoms reported by patients were red eyes, diplopia, and exophthalmos. When the intraocular pressure (IOP) was measured, 83.33% of the patients showed increased values. The mean IOP in the day-night intraocular pressure profile in the affected eye before intervention was 23.5 (± 2.7) mmHg compared to 14.1 (± 2.3) mmHg in the healthy eye. A significant difference could thus be demonstrated in side comparison (p = 0.0047). The post-interventional measurement showed a mean IOP of 15.3 (± 1.0) mmHg in the affected eye and thus a significant difference to the pre-interventional measurement in the affected eye (p = 0.0018). Four of the six patients with CSCF were taking antiglaucomatous eye drops before the intervention, and two patients after the intervention. The number of antiglaucoma drugs used could also be reduced.

CONCLUSION

Interventional fistula closure is an effective method for treating the secondary increase of IOP in CSCF. Successful closure of the fistula showed a significant reduction in IOP, which was not possible with the sole administration of antiglaucoma drugs. Radius-Maumenee syndrome should be considered as a differential diagnosis.

Patch Technique for Primary Treatment of Type A Carotid Cavernous Fistula: A Case Series and Technical Notes

BACKGROUND

The utilization of flow diverters (FDs) in the treatment of high-flow Type A carotid cavernous fistulas (CCFs) has been described before mainly as an adjunct to the traditional endovascular techniques and rarely as a stand-alone treatment. In this study, we retrospectively evaluated our experience with FDs as the solo nonadjunctive treatment of Type A CCF with severe cortical venous reflux (CVR).

METHODS

A retrospective review was performed of patients with Type A CCFs who were treated using FDs' patch technique (PT). Patients' demographics, clinical data, and preoperative and postoperative ocular examination were recorded. The procedure technique, pipeline embolization device (PED) diameters, and immediate and late procedure outcomes were described.

RESULTS

Three patients were included in this case series. All patients had history of trauma and presented with decreased visual acuity, cranial nerve II deficit, limited extraocular muscles' movement, and increased intraocular pressure (IOP). Diagnostic angiography was performed, which confirmed high-flow Type A CCF. Endovascular treatment was performed through distal radial access in 2 patients and femoral access in 1 patient by deploying 4 sequentially enlarging PEDs with immediate resolution of the ocular symptoms. Follow-up angiography confirmed complete resolution of CCF in 2 patients. One patient was lost to follow-up; however, angiogram at 4 months demonstrated residual small CCF with significant improvement from postprocedure angiogram.

CONCLUSIONS

The patch technique using sequentially enlarging FDs is a reasonable alternative solo technique for the treatment of direct CCF symptoms and results in immediate resolution of CVR while preserving the cavernous sinus anatomy.

RARE PRESENTATION OF BILATERAL CAROTID-CAVERNOUS FISTULA AS SUPRACHOROIDAL HEMORRHAGE DURING CATARACT SURGERY

OBJECTIVE

To report a rare case of suprachoroidal hemorrhage during phacoemulsification in a patient with bilateral carotid-cavernous fistula.

METHOD

Case report.

RESULT

A 76-year-old woman with underlying hypertension presented left eye poor vision due to an underlying dense cataract. Her initial preoperative assessment was uneventful, and she underwent phacoemulsification. During epinucleus removal, there was sudden, unexpected anterior chamber shallowing, resulting in posterior capsule rupture. While the surgeon extended the wound to facilitate epinucleus removal, there was a further decrease of red reflex, followed by hardening of the globe, indicating a suprachoroidal hemorrhage. The corneal wound was opposed swiftly without an intraocular lens. Further evaluation after that revealed the patient had a chronic headache for several years, and ocular examination showed bilateral esophoria. A computed tomography demonstrated features suggestive of bilateral carotid-cavernous fistula, which was confirmed with computed tomography angiography later.

CONCLUSION

Patients with carotid-cavernous fistula have elevated episcleral venous pressure and vortex venous pressure. Sudden decompression of the globe in these patients predisposes them to higher suprachoroidal hemorrhage risk, although this condition is generally rare in phacoemulsification.

Carotid cavernous fistula masquerading as orbital inflammation on noninvasive imaging in a peripartum patient

A carotid cavernous fistula (CCF) is a pathological connection between the internal or external carotid artery and the cavernous sinus venous system. Pregnancy has been proposed as a risk factor for spontaneous CCF, but the exact mechanism of risk is unknown. Overall, there are few published reports describing CCF in pregnancy. Study of this risk factor relationship is further complicated by potential ambiguity in diagnosing CCF, which may present as subtle, nonspecific findings on initial workup. We report a case of CCF during pregnancy in which the diagnostic process was notable for misleading, noninvasive, imaging studies.

Hemicranial postural headache as a first symptom of a spontaneous carotid cavernous fistula: A case report

RATIONALE

Spontaneous carotid cavernous fistula (CCF) is rare, and the expression of headache caused by it can be variable.

PATIENT CONCERNS

A case of a man hospitalized for high-intensity hemicranial headache which was aggravated by lying down and relieved when standing or sitting. The pain was of a pulsating character, localized on the right, behind the eye, followed by nausea and vomiting. He gradually appeared with ophthalmoplegia, decreased visual acuity and epistaxis.

DIAGNOSIS

Digital subtraction angiogram (DSA) showed a pseudoaneurysm arising from the internal carotid artery (ICA) that projected anteriorly and medially into the sphenoid sinus with occluded fistula.

INTERVENTIONS

The pseudoaneurysm was successfully treated with covered stent.

OUTCOMES

The patient was then followed up clinically at the outpatient and seen in the outpatient clinic with no further episodes of nasal bleeding or new neurologic deficit. The vision loss and ophthalmoparesis were unchanged.

LESSONS

Hemicranial postural headache may be the first and characteristic sign of spontaneous CCF.

Carotid-cavernous fistula from the perspective of an ophthalmologist A Review

Carotid-cavernous fistula (CCF) is an abnormal communication - vascular connection between arteries and veins in the cavernous sinus. Classification according to etiology is traumatic vs spontaneous. According to blood flow rate per high flow vs low flow fistula. According to anatomy of direct vs indirect: Direct (direct) CCF arises through direct communication between the internal carotid artery (ICA) and the cavernous sinus. Indirect CCF originates through indirect communication through the meningeal branches of ICA, external carotid artery and cavernous sinus (not directly with ICA) and Barrow type A, B, C, D division. Patients subjective complaints depend on the type of CCF. Most often it is pulsating tinnitus, synchronous with blood pulse. Typical findings include protrusion and pulsation of the eyeball, corkscrew vessels - arterialization of conjunctival and episleral vessels, increased intraocular pressure, not responding to local antiglaucomatous therapy, keratopathy a lagophthalmo, corneal ulcers. In the later untreated stages of CCF, secondary, venous stasis or central retinal vein occlusion can occur. Diagnostic procedures include B-scan and color Doppler ultrasonography, digital ophthamodynamometry, computer tomography, nuclear magnetic resonance and digital subtraction angiography. CCF can simulate orbitopathy, conjunctivitis symptoms, carotid occlusion, scleritis or cavernous sinus thrombosis. The ophthalmologist should recognize and indicate the necessary examinations in a timely manner. The therapy is ophthalmological, neuroradiological, sterotactic, surgical and conservative.

A shotgun wedding

A 69-year-old woman developed a carotid-cavernous fistula (CCF) after firing a shotgun. Initially, the patient had mild visual symptoms, but later on developed prominent features of CCF including chemosis, proptosis, ophthalmoparesis and conjunctival injection . The fistula was embolized via an intravascular coiling procedure. We are unaware of another patient who developed a CCF due to blunt force from shotgun use.