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Reid DM, Chalasani N, Khadka M, Kahlon S, Giangreco M. Cavernous Sinus Syndrome in a Polio-Afflicted Patient With Multiple Aneurysms. Cureus 2024; 16:e60673. [PMID: 38899274 PMCID: PMC11185984 DOI: 10.7759/cureus.60673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Cavernous sinus syndrome (CSS) is a complex, multifactorial condition that presents with a myriad of signs and symptoms including ptosis, double vision, and headache. We present the case of a 65-year-old woman with a chief concern of left-eye pain, including polio syndrome and hip replacement surgery. Unlike typical CSS cases often linked to tumors, this patient's condition involved a carotid-cavernous fistula (CCF), multiple internal carotid artery aneurysms, and a pericallosal aneurysm, without any associated tumor. She presented with severe left eye pain, ptosis, double vision, vomiting, headache, and other neurological symptoms since she woke up. Her treatment at a tertiary care center included diagnostic imaging, a cerebral angiogram, and embolization procedures, and she was discharged in stable condition. This case adds significant value to the medical literature by documenting the successful management of CSS with multiple aneurysms and a CCF, highlighting the importance of personalized treatment strategies and the effectiveness of modern embolization techniques in complex neurological conditions.
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Affiliation(s)
- Devaun M Reid
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Nishanth Chalasani
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Monica Khadka
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Sunny Kahlon
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Martin Giangreco
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
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Perng PS, Chang Y, Sun YT, Wang HK, Jiang YS, Lee JS, Wang LC, Huang CY. Endovascular treatment in bilateral cavernous sinus dural arteriovenous fistulas: a systematic review and meta-analysis. Sci Rep 2023; 13:7108. [PMID: 37528115 PMCID: PMC10394050 DOI: 10.1038/s41598-023-31864-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 03/20/2023] [Indexed: 08/03/2023] Open
Abstract
Few studies have discussed the disease nature and treatment outcomes for bilateral cavernous sinus dural arteriovenous fistula (CSDAVF). This study aimed to investigate the clinical features and treatment outcomes of bilateral CSDAVF. Embase, Medline, and Cochrane library were searched for studies that specified the outcomes of bilateral CSDAVF from inception to April 2022. The classification, clinical presentation, angiographic feature, surgical approach, and treatment outcomes were collected. Meta-analysis was performed using the random effects model. Eight studies reporting 97 patients were included. The clinical presentation was mainly orbital (n = 80), cavernous (n = 52) and cerebral (n = 5) symptoms. The most approached surgical route was inferior petrosal sinus (n = 80), followed by superior orbital vein (n = 10), and alternative approach (n = 7). Clinical symptoms of 88% of the patients (95% CI 80-93%, I2 = 0%) were cured, and 82% (95% CI 70-90%, I2 = 7%) had angiographic complete obliteration of fistulas during follow up. The overall complication rate was 18% (95% CI 11-27%, I2 = 0%). Therefore, endovascular treatment is an effective treatment for bilateral CSDAVF regarding clinical or angiographic outcomes. However, detailed evaluation of preoperative images and comprehensive surgical planning of the approach route are mandatory owing to complexity of the lesions.
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Affiliation(s)
- Pang-Shuo Perng
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan
| | - Yu Chang
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan
| | - Yuan-Ting Sun
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Advanced Optoelectronic Technology Center, National Cheng Kung University, Tainan, Taiwan
| | - Hao-Kuang Wang
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Shu Jiang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Shun Lee
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan
- Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Liang-Chao Wang
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan
| | - Chih-Yuan Huang
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan.
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Kaoutzani L, Rahimi SY. Headache, vision changes and cranial nerve palsy after head trauma. J Am Coll Emerg Physicians Open 2023; 4:e12938. [PMID: 37051505 PMCID: PMC10083543 DOI: 10.1002/emp2.12938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/08/2023] [Indexed: 04/14/2023] Open
Affiliation(s)
- Lydia Kaoutzani
- Department of NeurosurgeryMedical College of GeorgiaAugusta UniversityAugustaGeorgiaUSA
| | - Scott Y. Rahimi
- Department of NeurosurgeryMedical College of GeorgiaAugusta UniversityAugustaGeorgiaUSA
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Mathews B, Knight OJ. Carotid cavernous fistula secondary to ruptured carotid cavernous aneurysm causing orbital compartment syndrome. Am J Ophthalmol Case Rep 2022; 25:101310. [PMID: 35128158 PMCID: PMC8807974 DOI: 10.1016/j.ajoc.2022.101310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/28/2021] [Accepted: 01/18/2022] [Indexed: 11/02/2022] Open
Abstract
PURPOSE To report the rare presentation of orbital compartment syndrome secondary to formation of carotid cavernous fistula in the absence of trauma or surgery and demonstrate the role of emergent canthotomy/cantholysis as a vision saving procedure. OBSERVATIONS A 28-year-old African American female with obesity and migraines presented to the emergency department (ED) with the worst headache of her life after a severe episode of vomiting and dry heaving. Initial CT scan was negative for subarachnoid hemorrhage and patient was discharged. She re-presented to ED several days later with worsening proptosis and left eyelid edema and was discharged on oral antibiotics for presumed preseptal cellulitis after repeat CT scan. When seen by Ophthalmology in clinic, she was noted to have decreased vision, proptosis, decreased color perception, and double vision. She was noted to have orbital compartment syndrome requiring emergent canthotomy/cantholysis in the minor OR. She was sent back to ED for work-up, ultimately revealing a carotid cavernous fistula secondary to rupture of a carotid cavernous aneurysm. She was treated with several coil embolization procedures and ultimately her visual acuity rebounded to 20/20. CONCLUSIONS AND IMPORTANCE Orbital compartment syndrome may be a rare presentation of carotid cavernous fistula secondary to ruptured carotid cavernous aneurysm in the absence of trauma or surgery. Our case demonstrates the importance of properly assessing the cause of a red, edematous, proptosed eye in clinical setting and initiating an appropriate workup and treatment plan without delay.
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Affiliation(s)
- Basil Mathews
- Department of Ophthalmology, Kittner Eye Center at University of North Carolina, 2226 Nelson Highway, Chapel Hill, NC, USA
| | - O'Rese J Knight
- Department of Ophthalmology, Kittner Eye Center at University of North Carolina, 2226 Nelson Highway, Chapel Hill, NC, USA
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Ding CL, Zhang CL, Hua F, Xi SD, Zhou QW, Wang HJ, Chen JJ, Qiu J. Traumatic carotid-cavernous fistula with perimedullary venous drainage and delayed myelopathy: A case report. MEDICINE INTERNATIONAL 2021; 1:16. [PMID: 36698535 PMCID: PMC9829088 DOI: 10.3892/mi.2021.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/15/2021] [Indexed: 01/28/2023]
Abstract
Traumatic carotid-cavernous fistula (TCCF) with perimedullary venous drainage and delayed myelopathy is a relatively rare clinical lesion. Endovascular embolization using embolic agents is the preferred treatment for patients with a poor collateral circulation. The present study describes the case of a 45-year-old male with TCCF, who presented with progressive cervical myelopathy for 1 month. A previous history of the patient included an anterior skull base fracture induced by a traffic accident 2 years prior. Cervical spinal magnetic resonance imaging (MRI) revealed dilated perimedullary veins and cervical spinal cord edema. Cerebral digital subtraction angiography revealed a direct CCF with perimedullary venous drainage. The patient received endovascular treatment with coils and an Onyx liquid embolic system to occlude the fistula, and his symptoms were relieved when he was discharged 3 weeks later. The patient then felt normal and a cervical spinal MRI revealed the disappearance of the perimedullary veins dilation and spinal cord edema at the 6-month follow-up. To the best of our knowledge, only three cases of CCFs with perimedullary venous drainage presenting with myelopathy have been previously reported. The present study also discussed the possible pathological mechanisms for this rare presentation. Moreover, it is suggested that the possibility of CCFs as a cause of cervical myelopathy needs to be taken into consideration.
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Affiliation(s)
- Chun-Long Ding
- Department of Neurosurgery, Xishan People's Hospital, Wuxi, Jiangsu 214000, P.R. China
| | - Chun-Lei Zhang
- Department of Neurosurgery, 904th Hospital of Chinese People's Liberation Army Joint Logistic Support, Wuxi, Jiangsu 214000, P.R. China
| | - Feng Hua
- Department of Neurosurgery, Xishan People's Hospital, Wuxi, Jiangsu 214000, P.R. China,Correspondence to: Dr Feng Hua, Department of Neurosurgery, Xishan People's Hospital, 1128 Dacheng Road, Anzhen, Xishan, Wuxi, Jiangsu 214000, P.R. China
| | - Shao-Dong Xi
- Department of Neurosurgery, Xishan People's Hospital, Wuxi, Jiangsu 214000, P.R. China
| | - Qin-Wei Zhou
- Department of Neurosurgery, Xishan People's Hospital, Wuxi, Jiangsu 214000, P.R. China
| | - Hui-Jun Wang
- Department of Neurosurgery, Xishan People's Hospital, Wuxi, Jiangsu 214000, P.R. China
| | - Jun-Jie Chen
- Department of Neurosurgery, Xishan People's Hospital, Wuxi, Jiangsu 214000, P.R. China
| | - Jie Qiu
- Department of Neurosurgery, Xishan People's Hospital, Wuxi, Jiangsu 214000, P.R. China
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Tran T, Maingard J, Amukotuwa S, Seneviratne U. Bilateral spontaneous carotid-cavernous fistulae. Pract Neurol 2021; 21:261-263. [PMID: 33495281 DOI: 10.1136/practneurol-2020-002868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Tara Tran
- Department of Neurology, Monash Medical Centre Clayton, Clayton, Melbourne, Victoria, Australia
| | - Julian Maingard
- Department of Radiology, Monash Medical Centre Clayton, Clayton, Victoria, Australia
| | - Shalini Amukotuwa
- Department of Radiology, Monash Medical Centre Clayton, Clayton, Victoria, Australia
| | - Udaya Seneviratne
- Department of Neurology, Monash Medical Centre Clayton, Clayton, Melbourne, Victoria, Australia
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Jui-Chi Chang R, Kuang V, Meyer J, Chang E, Roberts-Thomson SJ, McKelvie P, Hardy TG, Pick ZS. Orbital giant cell myositis is an unusual and potentially lethal cause of bilateral ophthalmoplegia - A case report and literature review. Orbit 2020; 41:354-360. [PMID: 33297808 DOI: 10.1080/01676830.2020.1856144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We present a case of orbital giant cell myositis (OGCM), presenting with bilateral subacute progressive ophthalmoplegia and optic nerve dysfunction. An early extraocular muscle biopsy confirmed the diagnosis and guided appropriate management. Comprehensive investigation excluded any underlying systemic disease, including myocarditis. Twenty two months after presentation, the patient remains well on azathioprine with complete resolution of orbital signs.
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Affiliation(s)
| | - Vivian Kuang
- Department of Ophthalmology, Royal Melbourne Hospital, Parkville, Australia
| | - Joos Meyer
- Department of Ophthalmology, Royal Melbourne Hospital, Parkville, Australia
| | - Ewan Chang
- Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Australia
| | | | - Penny McKelvie
- Department of Anatomical Pathology, St. Vincent's Hospital, Parkville, Australia
| | - Thomas G Hardy
- Department of Ophthalmology, Royal Melbourne Hospital, Parkville, Australia.,Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Zelda S Pick
- Department of Ophthalmology, Royal Melbourne Hospital, Parkville, Australia
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Benson JC, Rydberg C, DeLone DR, Johnson MP, Geske J, Brinjikji W, Lanzino G, Cloft H, Luetmer PH. CT angiogram findings in carotid-cavernous fistulas: stratification of imaging features to help radiologists avoid misdiagnosis. Acta Radiol 2020; 61:945-952. [PMID: 31698923 DOI: 10.1177/0284185119885119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Carotid-cavernous fistulas (CCFs) are commonly misdiagnosed on computed tomography angiography (CTA). PURPOSE This study sought to identify the most sensitive and specific imaging features of CCFs on CTA. MATERIAL AND METHODS A retrospective review identified 18 consecutive patients suspected of having a CCF on CTA and subsequently underwent digital subtraction angiography (DSA). Two blinded reviewers assessed multiple findings on CTA: cavernous sinus asymmetry/enlargement; arterial-phase contrast in the cavernous sinus; proptosis; pre- or post-septal orbital edema; and dilated regional vasculature. Each was graded as positive, possible, and negative; "possible" was counted as positive. A third blinded reviewer served as a tiebreaker. RESULTS Of 18 patients, nine were true-positive and nine were false-positive. Superior ophthalmic vein early enhancement and dilatation had 100.0% sensitivity (95% confidence interval [CI] 40.0-100.0) and 77.8% specificity (95% CI 44.4-100.0); arterial-phase contrast in the cavernous sinus had 88.9% sensitivity (95% CI 44.4-100.0) and 66.7% specificity (95% CI 18.5-90.1); peri-orbital edema had 88.9% sensitivity (95% CI 35.5-100.0) and 77.8% specificity (95% CI 22.2-100.0). The most specific markers of CCF were superior petrosal sinus and inferior ophthalmic vein dilatation/enhancement (100.0%, 95% CI 88.8-100.0 and 88.9%, 95% CI 44.4-100.0, respectively); the specificity of asymmetric cavernous enlargement was 44.4% (95% CI 11.1-77.7). CONCLUSIONS Among patients in whom a CCF is suspected on CTA, superior ophthalmic vein dilatation/enhancement and arterial-phase contrast within the cavernous sinus are the most sensitive findings. Asymmetric cavernous sinus enlargement has poor specificity and may result in false-positive diagnoses of CCFs. False positive cases were less likely to have an optimally timed contrast bolus.
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Affiliation(s)
- John C Benson
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
| | | | - David R DeLone
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
| | - Matthew P Johnson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Geske
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Harry Cloft
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
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Laplant JF, Lim LH, Dumont AS, Nerva JD. Transvenous embolization of bilateral indirect carotid-cavernous fistulas via a unilateral transorbital approach. Orbit 2020; 40:320-325. [PMID: 32552143 DOI: 10.1080/01676830.2020.1779753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A 73-year-old man with a complex ophthalmologic history presented with several weeks of worsening diplopia, visual acuity, and proptosis bilaterally. Cerebral angiography demonstrated bilateral indirect Barrow type B carotid-cavernous fistulas (CCFs). Transarterial embolization was not attempted due to small arterial diameter and risk of stroke. Multiple attempts were made to access the fistula via a transfemoral venous approach and were unsuccessful. A transorbital puncture was performed, which allowed access to both cavernous sinuses via a unilateral approach. After embolization with Onyx, there was no residual fistula. The patient had a left-sided retrobulbar hematoma from the access. Right eye vision improved postoperatively.
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Affiliation(s)
| | - Lauren H Lim
- Department of Ophthalmology, Tulane University, New Orleans, USA
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane University, New Orleans, USA
| | - John D Nerva
- Department of Neurological Surgery, Tulane University, New Orleans, USA
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Law G, Docherty G. Dural carotid cavernous fistula following hypertensive emergency. BMJ Case Rep 2019; 12:e230823. [PMID: 31527207 PMCID: PMC6747910 DOI: 10.1136/bcr-2019-230823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2019] [Indexed: 11/03/2022] Open
Abstract
A 58-year-old woman was referred to the outpatient ophthalmology clinic with progressive bilateral eye redness and vision loss. She had presented 2 weeks earlier with an episode of hypertensive emergency. CT angiography revealed bilateral superior ophthalmic vein (SOV) dilation, prompting further workup with a cerebral angiogram. Subsequent imaging revealed an indirect (type D) carotid-cavernous fistula (CCF) with venous drainage into both SOVs and cavernous sinuses. Successful treatment of the CCF with coil embolisation required interdisciplinary teamwork between ophthalmologists and interventional neuroradiologists. The patient made a substantial visual recovery following treatment.
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Affiliation(s)
- Geoffrey Law
- Ophthalmology and Visual Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Gavin Docherty
- Ophthalmology, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Kasturi N, Kumari P, Nagarajan G, Krishnan N. Post-traumatic carotid-cavernous fistula with bilateral proptosis simulating cavernous sinus thrombosis. BMJ Case Rep 2019; 12:12/3/e227757. [PMID: 30936337 DOI: 10.1136/bcr-2018-227757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 48-year-old woman presented with bilateral non-pulsatile proptosis and ophthalmoplegia after 3 days following blunt orbital trauma. It was associated with fever, malaise and loss of vision in right eye. She was provisionally diagnosed with cavernous sinus thrombosis and was treated with intravenous antibiotics with no improvement. A subtle bruit was present on examination, and digital subtraction angiography revealed a right direct (type A) carotid-cavernous fistula (CCF). The patient underwent right coil embolisation of direct CCF. On follow-up at 4 months, her proptosis resolved completely and extraocular movements improved.
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Roper-Hall G. Acquired Ophthalmoplegia in Older Children and Adults. J Binocul Vis Ocul Motil 2018; 68:10-19. [PMID: 30196781 DOI: 10.1080/2576117x.2017.1421820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Ophthalmoplegia or ophthalmoparesis are the terms given to paralysis or paresis of one or more of the extraocular muscles in one or both eyes. It may be representative of serious neurological or systemic disease. Other mechanisms may cause limitation of eye movement, including restrictive or myasthenic conditions, or combinations of several etiologies. Evaluating and differentiating the mechanisms causing ophthalmoplegia is important in determining the correct diagnosis and selecting the appropriate management in these complex cases.
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Affiliation(s)
- Gill Roper-Hall
- a Department of Ophthalmology , Saint Louis University Medical Center , St. Louis , Missouri
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