Carotid cavernous fistula: an easily missed

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Presentation transcript:

Carotid cavernous fistula: an easily missed complication of head trauma Saptarshi Biswas, Arpit Amin CLINICAL PRESENTATION DISCUSSION INTRODUCTION Carotid cavernous fistula (CCF) are abnormal communication between the carotid arterial system and the cavernous sinus. CCFs may be classified based on etiology (spontaneous or acquired) and based on anatomy (direct or dural). We present a case of traumatic carotid cavernous fistula in a patient with basilar skull fracture. Traumatic CCFs most commonly occur as a result of basilar skull fracture. CCF can be classified into 4 types: - Type A are direct shunts between the Ica and cavernous sinus - Type B is a dural arteriovenous fistula (AVF) supplied by the ICA. - Type C is a dural AVF supplied by the ECA. - Type D is a dural AVF supplied by both ICA and ECA. The goal of treatment is to occlude the fistula site. Transarterial or transvenou endovascular embolization using metallic coils is the first line of treatment for traumatic CCFs with high blood flow. Open surgical intervention should be performed in cases where endovascular treatment is not possible or is unsuccessful. CLINICAL PRESENTATION This is a 26 year old female, who was involved in a motor vehicle collision and presented with symptoms of headache and diplopia. Physical exam showed left sided ptosis and restriction of left eye adduction, elevation, and depression. Rest of her neurologic exam was normal. Initial head CT scan performed at a community hospital showed basilar skull fracture and small frontal subarachnoid hemorrhage. One week after her traumatic injury, patient was transferred to our institution due to worsening headaches, diplopia, and inability to open her left eye. MRI/MRA of the brain showed basilar skull fracture along with carotid cavernous fistula. Patient underwent successful coil embolization of the carotid cavernous fistula. Her neurologic symptoms resolved after endovascular treatment of her carotid cavernous fistula. Figure 1 – MRA suspicious for carotid cavernous fistula (black arrow) CONCLUSION Our case presentation highlights the importance of having a high index of suspicion for carotid cavernous fistula in trauma patients with basilar skull fractures. Successful and timely endovascular coil embolization of carotid cavernous fistula can prevent development of disabling sequelae like complete visual loss. REFERENCES 1. Barrow DL, Spector RH, Braun IF. Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg. 1985;62(2): 248–256. 2. Korkmazer B, Kocak B, Tureci E et al. Endovascular treatment of carotid cavernous sinus fistula: a systematic review. World J Radiol. 2013;5(4):143- 155. 3. Yu S, Lee S, Shin H et al. Traumatic Carotid-Cavernous Sinus Fistula in a Patient with Facial Bone Fractures. Arch Plast Surg. 2015; 42 (6): 791- 793. Figure 2 : Completion angiogram view after coil embolization of carotid cavernous fistula