Diagnosis and follow-up study of carotid cavernous fistulas with color Doppler ultrasonography: analysis of 33 cases

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.

Diagnostic imaging in neuro-ophthalmology

Neuro-ophthalmology is a field combining neurology and ophthalmology that studies diseases that affect the visual system and the mechanisms that control eye movement and pupil function. Imaging tests make it possible to thoroughly assess the relevant anatomy and disease of the structures that make up the visual pathway, the nerves that control eye and pupil movement, and the orbital structures themselves. This article is divided into three sections (review of the anatomy, appropriate imaging techniques, and evaluation of disease according to clinical symptoms), with the aim of providing useful tools that will enable radiologists to choose the best imaging technique for the differential diagnosis of patients' problems to reach the correct diagnosis of their disease.

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.

A 32-year-old man with delayed onset post-traumatic proptosis and diplopia

BACKGROUND

Proptosis and motility deficits are common findings in the setting of craniofacial trauma, but can indicate the presence of vision and even life-threatening pathology.

OBJECTIVE

Our aim was to identify presentations consistent with traumatic carotid cavernous fistula (CCF) and to review the appropriate initial work-up and management.

CASE REPORT

A 32-year-old man came to our emergency department with proptosis, ocular motility deficits, and decreased vision 1 month after a restrained motor vehicle accident. An orbital bruit was auscultated and four-vessel angiography revealed a CCF. Covered stents and an embolic agent were used to abolish the arteriovenous communication and the patient rapidly returned to his premorbid baseline.

CONCLUSIONS

CCF is a relatively rare but important consequence of craniofacial trauma that must be recognized promptly in order to minimize the likelihood of serious sequelae. It should be suspected in patients with antecedent trauma presenting with exophthalmos, arterialized conjunctival vessels, and orbital bruit.

Update on imaging techniques in oculoplastics

Imaging is a beneficial aid to the oculoplastic surgeon especially in orbital and lacrimal disorders when the pathology is not visible from outside. It is a powerful tool that may be benefited in not only diagnosis but also management and follow-up. The most common imaging modalities required are CT and MRI, with CT being more frequently ordered by oculoplastic surgeons. Improvements in technology enabled the acquisition times to shorten incredibly. Radiologists can now obtain images with superb resolution, and isolate the site and tissue of interest from other structures with special techniques. Better contrast agents and 3D imaging capabilities make complicated cases easier to identify. Color Doppler imaging is becoming more popular both for research and clinical purposes. Magnetic resonance angiography (MRA) added so much to the vascular system imaging recently. Although angiography is still the gold standard, new software and techniques rendered MRA as valuable as angiography in most circumstances. Stereotactic navigation, although in use for a long time, recently became the focus of interest for the oculoplastic surgeon especially in orbital decompressions. Improvements in radiology and nuclear medicine techniques of lacrimal drainage system imaging provided more detailed analysis of the system.

Orbital varix thrombosis: a rare cause of unilateral proptosis

Orbital varices are thin walled, low flow, distensible veins which may rarely present with periorbital pain, proptosis or visual loss. Most orbital varices may be managed conservatively and only warrant surgery in the presence of recurrent thrombosis, disfiguring proptosis or acute visual loss. This report concerns an 84-year-old Caucasian woman who was admitted following a fall and noted to have isolated proptosis of the right eye, with vertical diplopia. All biochemical and haematological investigations were normal. A CT scan of the orbits demonstrated a serpiginous soft tissue mass within the superior portion of the right orbit, consistent with a thrombosed orbital varix. Conservative management was agreed with prism glasses and ophthalmological follow-up.

Advanced imaging applications for endovascular procedures

Advanced imaging techniques, particularly in CT and MRI, have become state-of-the-art to support the performance of interventional neuroradiologic procedures. Multidetector CT scanners with submillimeter detectors and real-time workstations have allowed the use of a noninvasive study, CT angiography, as a first-line diagnostic study at many institutions to detect and evaluate the morphology of aneurysms. Follow-up for postsubarachnoid spasm now includes transcranial Doppler, CT angiography, and sometimes perfusion to guide therapy. While both intracranial and extracranial stenosis have long been well evaluated by MR and CT angiography, information about the intimal wall and plaque morphology is now possible. In the setting of acute ischemia, CT with perfusion or MR with diffusion and perfusion has increased the ability to separate territory at risk from infarcted tissue, and can help to guide more appropriate intervention. This article addresses current state-of the-art imaging applications as well as a few techniques on the horizon that show great promise in helping to characterize those lesions amenable to endovascular therapy.

Post-traumatic pulsatile tinnitus: the hallmark of a direct carotico-cavernous fistula

Following trauma to her right frontal region, a 68-year-old woman suffered bilateral, benign, paroxysmal, positional vertigo and a left-sided, longitudinal petrosal bone fracture, with secondary facial palsy and ossicular luxation. From the onset, the patient complained of pulsatile, left-sided tinnitus. After eight weeks, she developed left-sided ocular symptoms, progressing from conjunctival hyperaemia and orbital oedema to an abducens nerve palsy, and ultimately to heart failure.

The case and the final diagnosis of carotico-cavernous fistula are discussed. Guidelines are proposed for a diagnostic approach to pulsatile tinnitus and for the optimal management of patients presenting with pulsatile tinnitus associated with ocular symptoms.

Diagnóstico precoz no invasivo de la fístula carótido-cavernosa postraumática por dúplex transcraneal color. Análisis de 4 pacientes

Posttraumatic carotid-cavernous fistula (PtCCF) is an uncommon complication after cranioencephalic trauma. It is usually diagnosed with a cerebral arteriography when the clinical symptoms have already appeared. The transcranial color-coded duplex sonography (TCDS) is a non-invasive technique at the patient's bedside that permits visualization of the circle of Willis and the intracavernous segment of the internal carotid artery. The initial sonographic patterns that suggest the presence of a PtCCF by TCDS are a mosaic image in color mode, presence of arterial and venous flows mixed with high velocity and low resistances. We present our experience in the early and non-invasive diagnosis of PtCFF in an Intensive Care Unit.