Diagnosis and postoperative monitoring of a traumatic carotid-cavernous fistula by jugular venous oximetry: case report and literature review

Imaging findings and outcomes in patients with carotid cavernous fistula at Inkosi Albert Luthuli Central Hospital in Durban

Background

Carotid cavernous fistulas (CCFs) are relatively uncommon and are difficult to diagnose clinically. Radiological imaging plays a significant role in making the diagnosis with recent advances improving the ability of radiologists to diagnose the condition. Despite these developments, digital subtracted angiography (DSA) remains the gold standard in diagnosing CCFs and simultaneously provides the opportunity for intervention.

Objectives

To determine the imaging findings of patients presenting to Inkosi Albert Luthuli Central Hospital (IALCH) with a CCF and to assess the outcome of endovascular intervention.

Method

We reviewed the electronic records and archived imaging data of consecutive patients diagnosed with CCF between January 2003 and May 2016 at IALCH, in particular, the imaging findings, intervention and subsequent outcomes.

Results

Computed tomography (CT) was the most utilised imaging modality prior to patients undergoing DSA. A dilated superior ophthalmic vein (96%) was the most prevalent imaging finding on axial imaging. At DSA, all except two patients had high-flow fistulas. The fistulas predominantly drained anteriorly (69.44%) and a cavernous internal carotid artery aneurysm was identified in eight patients. Occlusion of the fistula was attained in all patients that were compliant with follow-up and underwent intervention (n = 36, 100%), but parent artery sacrifice was required in 10 cases (27.78%).

Conclusion

A wide range of imaging modalities can be used in the workup of a CCF. CT is currently the most accessible modality in our setting, with limited access to magnetic resonance imaging. On axial imaging, a dilated superior ophthalmic vein is the commonest finding. Classification of a fistula according to flow dynamics and noting the presence of aneurysms or pseudoaneurysms was found to be more practical in comparison to the traditional Barrow’s classification. Management outcomes at our institution compare well with available local and international data.

Mastoid Epidermoid Tumor and Associated Dural Arteriovenous Fistula with Venous Sinus Occlusion

BACKGROUND

Dural arteriovenous fistula (DAVF) is an abnormal vascular connection between arterial and venous channels within dura mater. Although DAVFs have been linked to other types of intracranial tumors, this is the first case reporting the association between DAVF and an epidermoid tumor.

CASE DESCRIPTION

A middle-aged patient with chronic headache presented with Borden type II DAVF draining into the right transverse sigmoid junction and was also found to have an epidermoid tumor over the right mastoid. The patient underwent staged embolization of the fistula through both transvenous and transarterial routes. Continuous intraoperative venous pressure monitoring confirmed marked reduction in intracranial venous pressure, and the patient's symptoms completely resolved. However, the fistula still remained. The residual DAVF was then surgically disconnected, and the epidermoid tumor was resected in the same procedure.

CONCLUSIONS

This case demonstrates a DAVF can be associated with an epidermoid tumor. Tumor can compromise the venous outflow, which can then lead to intracranial venous hypertension and development of the DAVF. Venous pressure monitoring offers an objective method to verify resolution of venous hypertension, which might correlate with resolution of clinical symptoms.

Endovascular treatment of carotid-cavernous fistulas

Endovascular management has become the treatment of choice for carotid-cavernous fistulas regardless of the fistula type. The endovascular method offers numerous options that render it capable of treating each fistula type by choosing an adequate technique. This advantage along with the advancement in the field has led to fewer complications with higher success rate.