1. UNUSUAL CAROTID CAVERNOUS SINUS FISTULA ANIL KARAPURKAR Sir H N HOSPITAL MUMBAI

2. CCF ► BARROW CLASSIFICATION ► TYPE A : DIRECT ICA-CAV. SINUS ► TYPE B : BRANCHES OF ICA TO CAV. SIN ► TYPE C : BRANCHES OF ECA TO CAV. SIN ► TYPE D: BR. OF ICA & ECA TO CAV SINUS

3. V V ► GRADUAL ONSET SLOWLY PROGRESSIVE BILATERAL PROPTOSIS ► CONJUNCTIVAL EDEMA, CHEMOSIS ► BRUIT IN THE HEAD

4. VV

5. VV

6. V V ► FOLLOWING CORRECTION OF COARCTATION ► LEFT CAROTID- AORTIC BYPASS

7. VV AFTER CORRECTION OF COARCT

8. R P G ► RTA ► UNCONSCIOUS SINCE ACCIDENT ► RIGHT SIDED CHEMOSIS, OPHTHALMOPLEGIA ► NO BRUIT OVER EYEBALL

9. R P G Which artery ?

10. R P G COILING

11. B S ► 10 YEARS OLD RIGHT HANDED BOY FROM ORISSA, EASTERN INDIA ► SUDDEN ONSET SEVERE LEFT ORBITAL PAIN FOLLOWED BY SEVERE PROPTOSIS, CHEMOSIS ► SICK LOOKING PATIENT

12. B S CT Scan showing huge cavernous sinus & CCF

13. B S

14. MASSIVE ECA SUPPLY – DURAL AVF

15. B S Dural AVF right cavernous sinus

16. B S ARTERIAL ANEURYSM ON LEFT SCA

17. B S Excellent cross flow via AComm & PComm

18. B S ► NO TREATMENT ► FAMILY TOOK PATIENT AWAY

19. B S ► H/O RTA ► SMALL CAR TELESCOPED UNDER REAR OF TRUCK IN WINTER FOG ON 1 ST JAN ► TOP OF MARUTI SHEARED OFF ► SEVERE HEAD INJURY ► RIGHT TEMPORO FRONTAL COMPOUND DEPRESSED FRACTURE ► BRAIN HERNIA ► SEVERE ENT HEMORRHAGE ► NASAL PACKING BOTH NOSTRILS

20. B S ► CT SCAN ► EXTENSIVE SAH, BRAIN EDEMA ► FRACTURE GREATER & LESSER WING SPHENOID, ORBIT ► FRACTURE ANTERIOR CLINOID ► CAROTID INJURY SUSPECTED ► DSA DONE

21. B S GOOD CROSS FLOW VIA AComm, PComm FALSE ANEURYSM, SEVERE SPASM

22. B S ► NASAL PACK LEFT IN PLACE ► IN VIEW OF SPASM NO TREATMENT FOR ANEURYSM ► CRANIOTOMY FOR REPAIR OF DURA ► CARE TAKEN NOT TO FOLLOW FRACTURE OF ANT. CLINOID ► ELECTIVE VENTILATION FOR 3 DAYS

23. B S ► NASAL PACK REMOVED ON DAY3 FROM LEFT NOSTRIL ► RIGHT NOSTRIL REPACKED AS THERE WAS PERSISTENT OOZE ► PATIENT WEANED OFF VENTILATOR ► CONSCIOUS, OBEYING COMMANDS

24. B S ► DAY 4 SUDDEN INCREASE IN PROPTOSIS, CONJUNCTIVAL INJECTION, CHEMOSIS ► LATER IN THE DAY RECURRENT H’AGE FROM RIGHT NOSTRIL DESPITE PACK ► ANTERIOR & POSTERIOR PACKING OF BOTH NOSTRILS DONE

25. B S ► DAY 5 SEVERE RECURRENT H’AGE DESPITE PREVIOUS PACKING ► REPACKING ATTEMPTED TO NO AVAIL ► GOT RESIDENT TO COMPRESS CAROTID IN NECK ► WITH PRESSURE MAINTAINED PATIENT SHIFTED TO DSA

26. B S CCF AT SITE OF ANEURYSM

27. B S PRESSURE ON CAROTID CONTINUED EVEN AFTER BALLOON INFLATED, NOTE CCF DRANING VEIN

28. B S H’AGE STOPPED ONLY AFTER FULL INFLATION OF BALLOON

29. B S ► PATIENT TOLERATED OCCLUSION ► MILD LEFT HEMIPARESIS PERSISTED

30. F K ► 70 YEARS OLD RIGHT HANDED MALE ► 6’ PLUS GANGSTER OF WESTERN UP ► SHOT IN THE NECK ► BULLET ENTERED FROM LEFT EXITED FROM RIGHT ► ENTRY EXIT WOUNDS PACKED ► PATIENT TRANSFERRED TO OUR HOSPITAL

31. F K ► PLASTIC SURGEON EXPLORED RIGHT WOUND FIRST ► PROFUSE H’AGE COULD DO NOTHING REPACKED ► EXPLORED LEFT WOUND AGAIN PROFUSE H’AGE, REPACKED ► REFERRED FOR OPINION ► DSA ADVISED

32. B S CCF WITH DRAINAGE INTO NECK VEINS ON BOTH SIDES

33. B S GOOD CROSS FLOW VIA PComm, AComm

34. B S BALLOON OCCLUSION PACK REMOVED, NO H’AGE DISCHARGED NEXT DAY

35. R U ► 8 YEARS OLD BOY ► HIGH FEVER ► PROPTOSIS, CHEMOSIS, CONJUNCTIVAL EDEMA ► LOUD BRUIT ► SEPTIC THROMBOPHLEBITIS OF ORBIT

36. R U Treatment planned for next day Died during the night

37. A G ► PREVIOUSLY DOCUMENTED ANEURYSM RUPTURING INTO CAVERNOUS SINUS

38. A G ► 46 YEARS OLD FEMALE PATIENT ► SUDDEN ONSET LATERAL RECTUS PALSY ► FOUND TO HAVE BILATERAL ANEURYSMS OF CAVERNOUS ICA ► TREATED FOR RIGHT SIDED ANEURYSM WITH OCCLUSION COILS AT ANOTHER HOSPITAL

39. A G ► PRESENT HISTORY ► SUDDEN ONSET SPONTANEOUS PROTOSIS, CHEMOSIS, CONJUNCTIVAL INJECTION ► LOUD BRUIT OVER EYEBALL

40. A G LEFT CCF

41. B S COILS ON RIGHT BALLOON ON LEFT

42. N T ► ROAD TRAFFIC ACCIDENT ► ORBITAL INJURY, CHEMOSIS, ECCHYMOSIS ► 2 MONTHS LATER SUDEEN ONSET RAPIDLY PROGRESSIVE PROTPOSIS ► CONJUNCTIVAL INJECTION ► LOUD BRUIT OVER EYEBALL SYNCHRONOUS WITH PULSE ► BRUIT DISAPPEARS ON CAROTID COMPRESSION

43. N T DILATED OPHTHALMIC VEIN CAVERNOUS SINUS

44. N T TYPE A CCF

45. N T ANEURYSM SEEN AFTER OCCLUSION OF CCF

46. N T ► ANEURYSM MAY RUPTURE AFTER TREATMENT OF HIGH FLOW CCF ► ICA THEREFORE OCCLUDED

47. ISK ► RTA 1 MONTH EARLIER ► INJURY TO LEFT ORBIT ► COMPLETE OPHTHALMOPLEGIA ► GRADUAL REGRESSION OF CHEMOSIS ► REAPPEARANCE OF PROPTOSIS WITH CONJUNCTIVAL INJECTION ► LOUD BRUIT

48. I S K

49. 2 nd HOLE CCF SEEN AFTER FIRST CLOSED

50. I S K FOLLOW UP 1 MO. LATER 2 GIANT ANEURYSMS COMPRESSING ICA

51. I S K TEST OCCLUSION PERMANENT OCCLUSION

52. S M B ► GRADUAL ONSET PROPTOSIS ► PROGRESSIVE SINCE 4 MONTHS ► DIMINISHED VISION ► BRUIT OVER EYEBALL

53. S M B

54. A-V FISTULA OF PETROUS APEX DRAINING INTO OPHTHALMIC VEINS

55. S S ► RTA SEVERAL YEARS AGO ► LEFT SIDED CCF ► TREATED AT ANOTHER HOSPITAL MANY YEARS AGO ► RECURRENT PROPTOSIS, DIMINSHED VISION

56. S S

58. GLUE + COILS

59. A S CCF ON LEFT ICA, PROPTOSIS ON RIGHT

60. UNUSUAL CCF ► CONCLUSION ► CAREFUL PLANNING REQUIRED ► COMPLETE ANGIOGRAPHY ► LOOK AT COMPETITION BETWEEN VENOUS DRAINAGE OF BRAIN & CCF ► ATERIAL OR VENOUS ROUTE ► COMBINATION OF COILS, GLUE OR ONYX FOR COMPLEX CCF