A rare case of bilateral spontaneous indirect caroticocavernous fistula treated previously as a case of conjunctivitis

A "Mismatched" connection: a rare case of indirect or dural carotid-cavernous fistula: a case based review

Introduction and importance

A carotid-cavernous sinus fistula is an abnormal connection between the internal or external carotid artery and the venous system of the cavernous sinus. It represents a rare entity, and it is often misdiagnosed due to its overlapping symptoms with other conditions such as cavernous sinus thrombosis or orbital inflammation. Cerebral angiography continues to be the gold standard for diagnosis and surgical planning in patients with CCF, and the endovascular trans-venous approach still represents the primary line of treatment. Trans-arterial technique has become an excellent treatment option since the advent of embolic agents.

Case presentation

Here, the authors report the case of a 42-year-old male with a one-week history of impaired visual acuity, bilateral eye edema, eye redness, and ophthalmoplegia. A neuro-ophthalmological examination found proptosis, conjunctival chemosis, and sclera injection. Examination using MR venography and digital subtraction angiography (DSA) revealed an abnormal connection between the meningeal branch of the ICA, the ECA, and the cavernous sinus. The patient received endovascular treatment with Onyx injection into the facial vein with thrombosis of the anterior cavernous sinus. The patient presented an uneventful postoperative period and was symptoms-free on postoperative day 1.

Clinical discussion

CCF are rare and challenging conditions that require a multidisciplinary approach.

Conclusion

The endovascular treatment represents the gold standard and usually allows an effective interruption of the abnormal vascular connection with an almost immediate resolution of the preoperative signs and symptoms.

A Case of Spontaneous Bilateral Direct Carotid-Cavernous Fistula

A 92-year-old female with poorly controlled systemic hypertension presented with bilateral eye redness, lid fullness, conjunctival chemosis, ophthalmoplegia, and ptosis for two days. A neuro-ophthalmic evaluation revealed bilateral proptosis, severe conjunctival chemosis and congestion, and an almost complete bilateral ophthalmoplegia with a complete right superior eyelid ptosis. Computed tomography (CT) scans demonstrated bilateral dilation of the superior ophthalmic veins, and a CT angiography (CTA) showed a direct high-flow carotid-cavernous fistula (CCF) with secondary extraocular muscle enlargement. Clinicians should be aware that a typical direct high-flow CCF, although usually occurs after trauma and unilaterally, can present spontaneously without trauma and bilaterally.

Spontaneous resolution of nontraumatic bilateral Barrow Type D indirect carotid-cavernous fistulas: A case report

A Caucasian man in his 60s with a history of Cognard Type IIB dural arteriovenous fistula presented to the emergency room with right eye proptosis, chemosis, hyperemia, epiphora, diplopia, and blurred vision. Magnetic resonance imaging and magnetic resonance angiography revealed spontaneous, bilateral Barrow Type D carotid-cavernous fistulas (CCFs) that were later confirmed through cerebral angiography. The patient had no history of head or ocular trauma. Given the acute nature of presentation and worsening diplopia, the patient was scheduled for transvenous embolization. However, during the preprocedure angiogram, spontaneous resolution of the bilateral CCFs was observed. Complete resolution of all symptoms was noticed during follow-up. Given the rare nature of bilateral, indirect CCFs, our case stands out as the only reported instance whereby resolution of bilateral, indirect CCFs occurred spontaneously without any intervention.

Successful repair of spontaneous indirect bilateral carotid-cavernous fistula with coil embolization

Bilateral carotid-cavernous fistula (CCF) is a rare disease process, which portends poor visual outcome with delayed diagnosis and treatment. An 82-year-old woman presented with sudden onset of proptosis and decreased vision. A complete ophthalmologic examination along with magnetic resonance (MR) imaging of the brain and orbits, and MR angiography and venography of the brain confirmed the diagnosis of bilateral CCF. Diagnostic cerebral angiogram with concurrent coil embolization of the right cavernous sinus via left superior ophthalmic vein approach was performed. Bilateral indirect CCFs (type D CCF on the right and a type B CCF on the left) regressed completely after unilateral coil embolization. Visual acuity and limitation in extraocular movements significantly improved with complete resolution. In summary, we describe successful management of bilateral concurrent CCF with image-guided embolization and immediate recovery of vision and resolution of ophthalmological symptoms including proptosis and diplopia.