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... patient presented with left facial swelling, numbness, orbital pain, and severe headache caused by an unknown injury. A physical examination revealed limited extrinsic ocular motility (vertical movement), diplopia, exophthalmia, dilated conjunctival vessels, and conjunctival chemosis of the left eye (Fig. 1). Slightly decreased vision in his left eye was noted. An elevated intraocular pressure (27 mm Hg) was also observed in the left eye. Brain computed tomography (CT) was immediately performed, and epidural hemorrhage and pneumocephalus were detected. Facial bone CT revealed a zygomaticomaxillary complex fracture and a basal skull fracture with left sphenoid sinus wall fractures (Fig. 2). After conservative treatment for the intracranial hemorrhage in the intensive care unit, the patient's condition stabilized without neurologic complications. Open reduction and internal fixation of the facial bone fractures was performed 18 days after the injury. A left periorbital hematoma was meticulously removed. The patient's general symptoms gradually improved after ...
Citations
... The most indirect CCF occurs spontaneously and mostly as a degenerative change with hypertension and/or atherosclerosis. 6 The clinical presentation and symptom onset period can vary depending on the classification, size, and etiology. Early clinical features generally include the orbit due to the venous drainage route from the ophthalmic vein to the CS. ...
Carotid-cavernous fistula (CCF) is a rare condition. However, it should be suspected when there are traumatic facial fractures, because if not diagnosed, it can lead to permanent damage such as blindness. Traumatic CCF often presents delayed symptoms, and delayed diagnosis without prompt treatment can lead to permanent injuries in optic and cranial nerves III, IV, V, and VI as well as intracranial hemorrhage. The routine initial modality for patients with suspected facial bone fractures is noncontrast computed tomography (CT) to identify any fracture lines and check for intracranial hemorrhage. We report a post-traumatic CCF case with a 4-day symptom delay, where left superior ophthalmic vein (SOV) enlargement was observed on the routine noncontrast facial CT with ipsilateral orbital wall fracture. When the patient first presented to the emergency room (ER), we did not detect vein enlargement on CT. Afterwards, the patient developed delayed symptoms of CCF and was readmitted to the ER. When we reanalyzed the first CT scan, an enlarged SOV was confirmed. The diagnosis was confirmed via magnetic resonance imaging angiography, and the patient was successfully treated with embolization of the fistula. Thus, we recommend reviewing ophthalmic vein enlargement that is readily identifiable through noncontrast CT for patients injured by craniofacial trauma to suspect the presence of delayed CCF at their initial presentation.
... Alternatively, treatment of CCF may be conservative or interventional (endovascular intervention or neurosurgery) depending on the case [17,18]. Finally, source control for the infection was essential. ...
While swimming in the ocean on vacation in Cuba, a previously healthy 17-year-old female was unexpectedly stabbed through her orbit and into her brain by a needlefish. This is a unique case of a penetrating injury causing orbital cellulitis, retro-orbital abscess, cerebral venous sinus thrombosis and carotid cavernous fistula. After initial management at a local emergency department, she was transferred to a tertiary care trauma centre where she was treated by a team of emergency, neurosurgery, stroke neurology, ophthalmology, neuroradiology and infectious disease physicians. The patient faced a significant risk of a thrombotic event. There was careful consideration from the multidisciplinary team about the utility of thrombolysis or an interventional neuroradiology procedure. Ultimately, the patient was treated conservatively with intravenous antibiotics, low molecular weight heparin and observation. The patient continued to show clinical improvement several months later, which supported the challenging decision to opt for conservative management. There are very few cases to guide the treatment of this type of contaminated penetrating orbital and brain injury.
... These conservative treatments can be considered in patients with indirect CCFs (low flow; Type B and C) and patients with tolerable symptoms. Meanwhile, patients with direct CCFs (high flow; Type A) are less likely to achieve spontaneous resolution, thus have higher risks of developing progressive ocular symptoms, total loss of visual acuity, ischemic optic neuropathy, or even intracerebral and subarachnoid hemorrhage if left untreated [8]. The ideal management for these patients includes endovascular fistula-occlusion, such as detachable balloons, coils, embolic materials, and stents through a transarterial or transvenous route. ...
Background: Carotid cavernous fistulas (CCFs) have variable clinical presentation, imaging, and angiographic findings. The study aims to investigate the association of clinical presentations and radiological findings with flow dynamics from digital subtraction angiography (DSA) of CCFs patients. Methods: CCF patients who underwent DSA at Dr. Hasan Sadikin general hospital from January 2017 – December 2019 were included in this study. Patient’s characteristics, clinical presentations, and imaging results were retrieved from the patient’s medical record and radiology database. Fractures, proptosis, extraocular muscle thickening, superior ophthalmic vein dilatation, cavernous hyperdense lesion, and infarct are expected to be identified from imaging results. DSA identified types of flow dynamic based on Barrow classification and venous drainage patterns. Numeric data were analyzed by using Mann Whitney test, while categorical data were analyzed with Fisher’s exact test. Results: Twenty-eight patients were included in the study, with patients’ mean age was 30.5-year-old (range: 14- to 61-year-old), consisting of 19 males (67.9%) and 9 females (32.1%). In approximately 75% of the cases, the cause of CCF was a history of trauma. Patients with high flow CCFs were associated with the findings of cavernous sinus hyperdense and proptosis than patients with low flow. Patients who are presented with more than 1-year-long duration of symptoms were more likely to have more than 1 draining vein, compared to patients who are presented with < 1-year-long duration of symptoms. Conclusions: History of trauma, longer duration of symptoms, and the presence of a hyperdense cavernous lesion on head CT scan results require further angiographic study prior to endovascular intervention.
... 1,6 Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are the modalities to depict the pathologies in the peripheral associated with CCFs. 10,11 The aim of treating patient with CCF is to occlude the fistula site, either manual or radiosurgical intervention, and endovascular embolization for high blood flow management. 2,10,11 Untreated fistula can cause a serious complication, such as loss C CAS E REPORT of vision and ischemic optic neuropathy. ...
... 10,11 The aim of treating patient with CCF is to occlude the fistula site, either manual or radiosurgical intervention, and endovascular embolization for high blood flow management. 2,10,11 Untreated fistula can cause a serious complication, such as loss C CAS E REPORT of vision and ischemic optic neuropathy. 11 We reported a rare case of bilateral traumatic carotid cavernous fistulas in clinical practice and published articles. ...
... 2,10,11 Untreated fistula can cause a serious complication, such as loss C CAS E REPORT of vision and ischemic optic neuropathy. 11 We reported a rare case of bilateral traumatic carotid cavernous fistulas in clinical practice and published articles. The purpose of this paper is to help ophthalmologist making an early diagnosis and prompt treatment to prevent it from serious complications. ...
Objective : To increase the awareness for ophthalmologist in diagnosing rare case of bilateral traumatic carotid cavernous fistula that could lead to serious complications. Case description : A 44 years old woman came with chief complaint of squint and diplopia since one month after traffic accident. She had been underwent orbital bone fracture repair at previous hospital immediately. There was complaint of headache, blurred vision, double vision and pain on the eyes one month after trauma. There was no history of redness or proptosis. Examination revealed 6/6 for the right and 6/8.5 for the left eye corrected visual acuity, 30 degrees exotropia, normal intraocular pressures (IOP), restriction on eyes movement especially on the left eye, normal anterior and posterior segment, and no bruit. CT orbital revealed bilateral dilated and tortuous of the ophthalmica vein with suspicious of carotid cavernous fistula (CCF). Patient developed slowly progressive conditions such as proptosis non axial on the left eye, redness with corkscrew appearance on both eyes, restriction of the ocular movement and also founded bruit on both eyes within two months follow up. CT angiography revealed CCF bilateral type A. Patient underwent digital subtraction angiography (DSA) and balloon embolization four months after diagnosed. Conclusion : Although bilateral carotid cavernous fistula is a rare case, performing a suitable diagnostic examination would help to prevent devastating outcome. Prognosis depends on severity and time span from symptoms to treatment.
... The key to this success of endovascular approach is tailoring to individual cases according to the type, anatomy, and extent of each fistula. 17,18 references ...
A carotid cavernous fistula (CCF) is an abnormal vascular connection between the carotid arterial system and the cavernous sinus. Traumatic head injury, particularly basilar skull fractures, can result in a type A CCF. Type A CCFs are direct, high-flow shunts between the internal carotid artery and the cavernous sinus. Significant neuro-ophthalmologic sequela can result from such connections, including visual loss. These fistulas are commonly missed on the routine imaging completed following head trauma. If suspected, a cerebral angiography is the gold standard imaging modality, with endovascular coiling being the preferred treatment. Physicians should have a high index of suspicion for CCFs in trauma patients presenting with basilar skull fractures. Prompt recognition and treatment can resolve symptoms and prevent permanent sequela. resumen Una fístula cavernosa carotídea (CCF) es una conexión vascular anormal entre el sistema arterial carotídeo y el seno cavernoso. La lesión traumática de la cabeza, particularmente las fracturas del cráneo basilar, pueden dar como resultado un CCF tipo A. Los CCF tipo A son derivaciones directas de flujo alto entre la arteria carótida interna y el seno cavernoso. Secuelas neuro-oftalmológicas importantes pueden ser el resultado de tales conexiones, incluida la pérdida visual. Estas fístulas se pasan por alto con frecuencia en las imágenes de rutina completadas después de un traumatismo craneal. Si se sospecha, una angiografía cerebral es la modalidad de imagenología estándar, siendo el tratamiento preferido la inserción endovascular. Los médicos deberían tener un alto índice de sospecha de fístulas cavernosas carotídeas en pacientes con trauma que presenten fracturas de cráneo basales. El reconocimiento y el tratamiento oportunos pueden resolver los síntomas y prevenir la secuela permanente. Palabras clave: Fístula cavernosa carotídea, Lesión en la cabeza, Traumatismo cerrado.
... Indirect CCF refers to communication between the cavernous sinus and one or more branches of either or both the ICA or external carotid artery. Indirect CCF occurs mostly as a degenerative process in older patients with systemic hypertension and/or atherosclerosis [2,3]. ...
... Delayed contralateral traumatic carotid cavernous fistula after craniomaxillofacial fractures CCF following craniomaxillofacial trauma are summarized in Table 1 [3][4][5][6][7][8][9][10][11][12]. We report a unique case of delayed CCF that developed symptoms 7 months after a craniomaxillofacial fracture and on the side opposite to that of the fracture. ...
... Moreover, it can block the drainage of aqueous humor and increase intraocular pressure, which interferes with retinal perfusion and results in reduced visual acuity. In case of severe eye edema, the cranial nerves may become compressed and ischemia may develop in cranial nerves III, IV, V, and VI [3]. The optimal treatment for direct CCFs involves closure of the abnormal arteriovenous communication and preservation of ICA patency. ...
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.
... Carotid-cavernous fistulas (CCFs) are abnormal shunts between the carotid artery system (internal, external, or both) and the cavernous plexus [1]. Though they can originate through different mechanisms, 75% are due to blunt or penetrating traumatic injury of the carotid arteries [2,3]. ...
... CCFs can be classified according to their etiology (traumatic or spontaneous), hemodynamics (high-or low-flow), and anatomy (direct or indirect) [1,4]. Clinical presentation varies widely and may be characterized by proptosis, conjunctival hyperemia, chemosis, headache, and/or cavernous sinus nerve palsies (e.g., ophthalmoplegia or hypoesthesia of the superior segment of the face). ...
... Traumatic CCF is less likely to resolve spontaneously and can lead to progressive ocular symptoms and eventual total loss of visual acuity and ischemic optic neuropathy if left untreated [1]. The treatment goal is to completely occlude the fistula while preserving flow within the ICA. ...
Background:
Carotid-cavernous fistula (CCF) is a shunt between the carotid artery and the cavernous sinus. Traumatic CCFs are diagnosed in 0.2% of head traumas being only 4.6% of the pediatric population. Classified by Barrow in 1985, type A CCF is the most frequent, occurring in 75% of cases. Type A is characterized by direct and high-flow CCF that generally can occur as a result of traumatic injury or rupture of an intracavernous aneurysm.
Case presentation:
The subject was an 8-year-old boy with penetrating trauma to his left eye. During the initial evaluation, a computed tomography (CT) scan was unremarkable, and after relief of symptoms, the patient was discharged. Seven days later, he developed grade I proptosis, conjunctival chemosis, ophthalmoplegia (III, IV, and VI cranial nerve palsies), and left-sided ptosis and mydriasis. Arteriography confirmed a post-traumatic CCF, and the patient was treated with an endovascular detachable balloon.
Conclusion:
CCF should be suspected in craniofacial traumas with ocular symptoms. The presence of a skull base fracture on CT is a poor predictor of CCF associated with head trauma. Early diagnosis and treatment can prevent permanent neurological deficits and unfavorable outcomes.
Traumatic carotid-cavernous fistula (TCCF) is a rare occurrence in the pediatric population. However, the neurological sequelae of TCCF are associated with higher morbidity and mortality in pediatric patients. We report the case of a 2-year-old child with TCCF treated at a public hospital in Peru. The etiology of the injury was due to a fall of approximately 5 meters. The diagnosis was made based on the clinical picture and neuroimaging findings. The initial proposed treatment was performed with the hope of preserving the parent artery; however, due to persistence of the TCCF, embolization of the parent artery with coils and embolizing substance was performed. A literature review of similar cases was performed and identified eight cases in children under 10 years of age. Endovascular management of an acute TCCF is a challenge due to the high morbidity and mortality during the acute phase and can be complicated when other traumatic injuries are present. Maintaining the parent artery is important; however, when this is not possible, trapping the parent artery may provide an alternate option when appropriate collaterals exist.
Many abnormalities of the orbit present with neuro-ophthalmic findings, such as impaired ocular motility or alignment, and sensory changes, including optic neuropathy. Comprehensive coverage of all orbital diseases is beyond the scope of this article. This review focuses on diagnosis and management of the most common and the most vision- or life-threatening orbital conditions as well as more recently discovered entities and points of active controversy. These conditions include orbital trauma, vascular disease, inflammatory and infectious diseases, and neoplasms. Common presenting symptoms and associated neuro-orbital diseases also are summarized.
