Traumatic carotid-cavernous sinus fistula accompanying abducens nerve (VI) palsy in blowout fractures: missed diagnosis of ‘white-eyed shunt’

Contralateral traumatic carotid cavernous fistula after a craniomaxillofacial fracture

Introduction

Carotid-cavernous fistula is an abnormal communication between the internal carotid artery, the external carotid artery or any of their branches and the cavernous sinus. This condition may occur spontaneously or after craniofacial trauma; in this case the fistula takes place on the same side as the craniofacial fracture and becomes symptomatic within a few weeks. The diagnosis is clinical; it must be evoked before any post-traumatic proptosis. Treatment must be started quickly to avoid visual or even vital complications.

Case presentation

We report the case of a 19 years old male patient who was admitted to the maxillofacial surgery department for osteosynthesis of a fracture of the left orbital roof after a traffic accident. The three-month's examination noted a right pulsatile proptosis with redness and decrease of the visual acuity. The cerebral MRI was in favor of a right sided direct CCF, which was confirmed by the arteriographie. The patient responded very well to embolization.

Discussion

Craniofacial trauma is a major cause of carotid cavernous fistula. When a patient has ophthalmic manifestations of vascular complications, early detection of CCF is important for preserving visual acuity. The diagnosis is mainly clinical based on the ophthalmological symptoms. CT and MRI scans show the indirect signs of the fistula. There are several types of invasive and non-invasive treatments. The evolution of the fistula is generally favorable and recurrence is not very frequent.

Conclusion

This case report is a documentation on an exceptional case of posttraumatic direct CCF occurring on the contralateral side of the skull base fracture.

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Posttraumatic carotid-cavernous fistula in a rare complication of craniofacial trauma.

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Contralateral CCF to the fracture side is even more exceptional.

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CCF's complications can be both invalidating and life threatening.

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The prognosis depends on the etiology and the therapeutic delay.

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Before an exophthalmic and ocular redness, it is always necessary to think of a cavernous carotid fistula especially when there has been a recent trauma.

Delayed contralateral traumatic carotid cavernous fistula after craniomaxillofacial fractures

A carotid-cavernous sinus fistula is a rare condition in which an abnormal communication exists between the internal or external carotid artery and the cavernous sinus. It typically occurs within a few weeks after craniomaxillofacial trauma. In most cases, the carotid-cavernous sinus fistula occurs on the same side as the craniomaxillofacial fracture. We report a case of delayed carotidcavernous sinus fistula that developed symptoms 7 months after the craniomaxillofacial fracture. The fistula developed on the side opposite to that of the craniomaxillofacial fracture. Based on our experience with this case, we recommend a long follow-up period of 7–8 months after the occurrence of a craniomaxillofacial fracture. We also recommend that the follow-up should include consideration of the side contralateral to the injury.

Endovascular treatment of carotid-cavernous vascular lesions

Objective:

to evaluate the endovascular treatment of vascular lesions of the cavernous segment of the internal carotidartery (ICA) performed at our institution.

Methods:

we conducted a descriptive, retrospective and prospective study of patients with aneurysms of the cavernous portion of the ICA or with direct carotid-cavernous fistulas (dCCF) undergoing endovascular treatment.

Results:

we included 26 patients with intracavernous aneurysms and ten with dCCF. All aneurysms were treated with ICA occlusion. Those with dCCF were treated with occlusion in seven cases and with selective fistula occlusion in the remaining three. There was improvement of pain and ocular proptosis in all patients with dCCF. In patients with intracavernous aneurysms, the incidence of retro-orbital pain fell from 84.6% to 30.8% after treatment. The endovascular treatment decreased the dysfunction of affected cranial nerves in both groups, especially the oculomotor one.

Conclusion:

the endovascular treatment significantly improved the symptoms in the patients studied, especially those related to pain and oculomotor nerve dysfunction.

Objetivo:

avaliar o tratamento endovascular de lesões vasculares da artéria carótida interna (ACI), segmento cavernoso, realizado na Santa Casa de São Paulo.

Métodos:

estudo descritivo, retrospectivo e prospectivo, de pacientes com aneurisma da porção cavernosa da ACI ou com fístulas carótido-cavernosas diretas (FCCd) submetidos a tratamento endovascular.

Resultados:

foram incluídos 26 pacientes com aneurismas intracavernosos e dez com FCCd. Todos os aneurismas foram tratados com oclusão da ACI. Os com FCCd foram tratados com oclusão, em sete casos, e com oclusão seletiva da fístula nos outros três. Houve melhora da dor e proptose ocular em todos os pacientes com FCCd. Nos pacientes com aneurisma intracavernoso, a incidência de dor retro-orbitária caiu de 84,6% para 30,8% após o tratamento. Após o tratamento endovascular houve uma melhora importante da disfunção de nervos cranianos afetados em ambos os grupos, sobretudo no nervo oculomotor.

Conclusão:

o tratamento endovascular trouxe melhora para os pacientes deste estudo, especialmente nos critérios dor e acometimento do nervo oculomotor.

Carotid-Cavernous Fistula as a Complication of Panfacial Fracture: Case Report 11 Years after the Surgery

The carotid-cavernous fistula (CCF) is a rare complication in patients victimized by craniofacial trauma. It involves multidisciplinary medical action. Owing to its potential complications, it is essential that maxillofacial surgery and neurosurgery specialists diagnose this condition so that appropriate treatment can be performed. The authors present a report of a case 11 years after the surgery.

Traumatic carotid-cavernous fistula in a multiple facial fractures patient: case report and literature review

Carotid-cavernous fistula (CCF) is a pathologic communication between internal carotid artery (ICA) and cavernous sinus (CS). CCF occurs most commonly in association with craniofacial trauma. Traumatic CCFs are very rare, occurring in 0.17-0.27% of craniomaxillofacial trauma cases. We present a case of the patient treated for multiple facial fractures, who developed symptoms of CCF with several days latency and was successfully treated by endovascular occlusion of ICA. Anatomy of CS, pathophysiology of CCFs and treatment options are concisely reviewed.

Traumatic carotid-cavernous fistula at the anterior ascending segment of the internal carotid artery in a pediatric patient

INTRODUCTION

Traumatic carotid-cavernous fistula (CCF) in children is a rare condition. Early diagnosis and treatment is still a challenge, and it is associated with good neurological recovery.

CASE SUMMARY

We present a rare case of a 10-year-old boy with mild head trauma, who developed a CCF at the anterior segment of the ascending internal carotid artery. The patient was treated with endovascular coil embolization and evolved with a favorable outcome.

DISCUSSION

Most of reports in the literature address the traumatic CCF in adult patients, in which early treatment may prevent poor recovery or fatal outcomes. The diagnosis and management of this condition are discussed based on a literature review.

CONCLUSION

It is important to keep a high degree of suspicion for CCF, especially in traumatic head injury associated with skull base fracture, since the early diagnosis and treatment may prevent potentially permanent neurological deficits.