Carotid Cavernous Fistula

Carotid-cavernous fistulas (CCFs) are abnormal communications between the carotid arterial system and the venous cavernous sinus. Most often, CCFs are broadly classified as either direct or indirect, as depicted on angiograms. Further classification is based on their etiologic and hemodynamic qualities. Clinical manifestations of CCFs frequently involve ophthalmologic abnormalities. The rate of flow through the CCF was moderate at the time of the first angiogram, and because of the right hemispheric infarction and other injuries, a decision regarding treatment of the CCF was deferred.A carotid-cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus .

The clinical manifestations of carotid cavernous fistula, an abnormal arteriovenous connection between the cavernous sinus and the carotid artery, can closely mimic the cardinal signs of Graves' ophthalmopathy.The Carotid Cavernous Fistula an inflammatory disorder of the orbit usually associated with autoimmune thyroid disease.Carotid Cavernous Fistula may result from trauma to the base of the skull or from the rupture of a saccular aneurysm . Symptoms of CCF are conjunctival chemosis , pulsating exophthalmos and a cranial bruit. Carotid Cavernous Fistulais distinguished from a cavernous sinus thrombosis by the rapidity of symptoms. CCFs can be treated with selective embolization and detachable balloon occlusion.

Symptoms of Carotid Cavernous Fistula

The most common symptoms of Carotid Cavernous Fistula:

• Patients who develop a CCSF traumatically have pronounced symptoms and signs. There will be marked congestion of the eyelids, conjunctiva and orbit.
• There is typically proptosis (which is often pulsatile) and limitation of ocular movement. Also, the patient will experience vision loss from a host of possible causes, including secondary glaucoma, exposure keratopathy, and retinal and optic nerve ischemia.
• The symptoms of the patient improved over the next 2 weeks and she was finally discharged with an improved vision.
• The patient may experience diplopia and ophthalmoplegia (often from CN VI palsy), tinnitus or orbital bruit, and a red, congested eye that is often mistreated as an ocular infection or inflammation.

Treatment of Carotid Cavernous Fistula

Some treatment of Carotid Cavernous Fistula:

• The embolization in our case was done under general anesthesia maintaining normocapnia.
• There was a less concern in our minds regarding normal perfusion pressure breakthrough as the patient had symptoms of short duration.
• The goal of therapy in carotico-cavernous fistula is to preserve and improve vision and return of the orbit and its contents to normal
• The patient underwent iv steroid treatment with 1 g methylprednisolone acetate in 500 ml saline infused over 24 h for 3 consecutive d, followed by an oral regimen of 75 mg prednisone/d for 3 wk, with subsequent tapering and discontinuation after 3 months.
• After the treatment, improvement of congestive symptoms in the left eye was noticed, whereas only mild contralateral changes were observed.

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