Carotid-cavernous fistula associated with an intracranial lesion caused by cortical venous reflux

Neuropsychiatric Presentation in Indirect Carotid-Cavernous Fistula: A Case Report

Carotid-cavernous fistula (CCF) is a rare sight and potentially life-threatening disorder arising from an abnormal connection between the carotid artery and the cavernous sinus. It can be classified into direct or indirect according to different arteriovenous shunts. Direct CCF usually has dramatic ocular presentations, whereas indirect CCF has a more insidious course and may be associated with neurologic symptoms in posteriorly draining fistulas. A 61-year-old gentleman presented with five days history of altered behavior and double vision preceding a bulging left eye. Ocular examination showed left eye proptosis, generalized chemosis, total ophthalmoplegia, and raised intra-ocular pressure. Computed tomography angiography (CTA) brain and orbit demonstrated dilated superior ophthalmic vein (SOV) with communication to a tortuous cavernous sinus suggestive of carotid-cavernous fistula (CCF). Digital subtraction angiography (DSA) eventually confirmed the presence of indirect communication between branches of the bilateral external carotid artery (ECA) and left cavernous sinus, which is a type C indirect CCF according to the Barrow classification. Total embolization of left CCF was successfully achieved via transvenous access. A marked reduction of proptosis and intra-ocular pressure was noted following the procedure. Although rare, neuropsychiatric presentation could be a possible presentation of CCF, and treating physicians should be aware of it. A high index of suspicion and prompt diagnosis is crucial in managing this sight and life-threatening condition. Early intervention can improve the prognosis of patients.

Bilateral Carotid-Cavernous Fistula: A Diagnostic and Therapeutic Challenge

Carotid-cavernous fistula (CCF) is an aberrant communication between the main trunk or branches of carotid artery and the cavernous sinus. Most of the cases of CCF occur following head trauma, but congenital and spontaneous cases have been reported. We report an interesting case of bilateral CCF with no history of trauma, thus most likely spontaneous form. Since it is rare, it was a diagnostic challenge. The suspicion of this diagnosis was made due to clinical features of headache, signs of increased Intracranial Pressure (ICP) (nausea, vomiting, and worsening headaches during Valsalva), exophthalmos, periorbital edema, periorbital erythema, chemosis, and conjunctival injection in both eyes. It was diagnosed with a 4-vessel angiography (digital subtraction angiography) which is the gold standard and was managed successfully with endovascular coil embolization.

Relationship of clinical presentation and angiographic findings in patients with indirect cavernous carotid fistulae

Introduction

Indirect cavernous carotid fistulae (ICCFs) can present with insidious, non-specific symptoms and prove difficult to diagnose. This study evaluates associations among ICCF symptoms and angiographic findings.

Methods

A retrospective analysis was performed of prospectively maintained records at four medical centers to identify patients with ICCFs evaluated with angiography. Patient demographics, symptoms, and angiographic findings were tabulated. Univariate and multivariate analyses were conducted to identify associations among these variables.

Results

Records sufficient for review existed for 267 patients evaluated with angiography. Patients were most commonly women, in the sixth or seventh decade of life, and had symptoms for months before a definitive diagnosis. The most common symptoms included proptosis, diplopia, cranial nerve palsy, and chemosis. Cortical venous reflux was most common in patients with chemosis, orbital pain, or bruit. Intracranial hemorrhage was associated with cortical reflux and bilateral inferior petrosal sinus occlusion. Patients with loss of symptoms demonstrated higher rates of inferior petrosal sinus occlusion and a trend towards rupture.

Conclusion

A high index of suspicion is needed to promptly diagnose patients with ICCFs. High risk features are more common in the setting of chemosis, orbital pain, bruit, or spontaneous loss of symptoms. Patients with such symptoms warrant expedited angiographic evaluation.

Thrombosis of venous outflows of the cavernous sinus: possible aetiology of the cortical venous reflux in case of indirect carotid-cavernous fistulas

BACKGROUND

The presence of a cortical venous reflux (CVR) in a carotid-cavernous fistula (CCF) is well described and is considered to be a criterion for urgent treatment. This reflux is often associated with direct/traumatic CCF and the high-flow of the fistula alone explains the reflux. For indirect CCF, the pathophysiology of a CVR is unclear.

METHODS

All patients treated endovascularly for an indirect CCF with a cortical venous reflux between 2003 and 2015 were included. We retrospectively analysed data focusing on whether venous outflows of the cavernous sinus would opacify or not with the local injection of contrast, in order to locate those that could explain the venous reflux.

RESULTS

Twenty consecutive patients (male/female ratio, 2/3) were included in this series with a mean age of 63 years. All patients presented ocular signs and no patients showed any neurological sign secondary to the CVR. We distinguished four patterns of CVR: in the superficial middle cerebral vein (75%), in the uncal vein (15%), in the superior petrosal vein (5%) and in the inferior petrosal vein (5%). Seventy percent of the cases presented a lack of opacification in more than three venous outflows of the CS involved. Each patient received an endovascular therapy by venous approach with a success rate of 76.9% per embolisation session. Two patients (10%) presented a permanent ocular paresis and two others a transient deficit.

CONCLUSIONS

CVR is directly correlated with the thrombosis of multiple venous outflows of the CS. The "non-opacification" of at least three of the CS venous outflows is necessary for the development of CVR. Such thrombosis may be explained by the combination of haemodynamic and inflammatory changes of the venous wall.

Dural carotid-cavernous fistula presenting with confusion and expressive aphasia

We report a patient who presented with confusion and expressive aphasia at the onset of a cortical venous reflux (CVR) related to a known dural carotid-cavernous fistula (DCCF). CVR and venous congestion are rare findings in a DCCF, however, it is important to recognize these findings early to reduce the associated risks of venous hemorrhage and infarction. To our knowledge, no previous report has described an association of expressive aphasia with CVR from a DCCF. This patient highlights the potential for venous congestion secondary to CVR from a DCCF presenting with a constellation of symptoms, including confusion and expressive aphasia with corresponding MRI findings. Clinicians should consider a DCCF in the differential diagnosis of this clinical presentation, with corroborative imaging findings.