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 Table of Contents  
PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 850-851

Post-traumatic direct carotico-cavernous fistula following trauma to the contralateral side


1 Department of Ophthalmic Plastic Surgery, Orbit and Ocular Oncology, PBMA's H V Desai Eye Hospital, Pune, Maharashtra, India
2 Department of Radiology, Ruby Hall Clinic, Pune, Maharashtra, India

Date of Submission21-Dec-2020
Date of Acceptance06-May-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Sonal P Yadav
Department of Ophthalmic Plastic Surgery, Orbit and Ocular Oncology, PBMA's H V Desai Eye Hospital, Mohammed Wadi, Pune, Maharashtra - 411 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3735_20

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  Abstract 


Keywords: Carotico-cavernous fistula, embolization, endovascular, trauma


How to cite this article:
Yadav SP, Chavan R, Bharucha KM, Deshpande RD. Post-traumatic direct carotico-cavernous fistula following trauma to the contralateral side. Indian J Ophthalmol Case Rep 2021;1:850-1

How to cite this URL:
Yadav SP, Chavan R, Bharucha KM, Deshpande RD. Post-traumatic direct carotico-cavernous fistula following trauma to the contralateral side. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 28];1:850-1. Available from: https://www.ijoreports.in/text.asp?2021/1/4/850/327633



A 22-year-old gentleman sought consult for noticing double vision, forward protrusion of the left eye with dull pain, and whooshing sound in his left ear for 15 days. He had suffered trauma to his right side of the face following a road traffic accident 2 months back. The computed tomography (CT) at the time of injury showed maxillofacial fractures on the right side, and his records suggested that they were managed conservatively. On examination, he showed the left-sided pulsatile axial proptosis, dilated episcleral vessels with bruit over the orbit and temporal fossa, diplopia, restricted elevation as well as abduction [Figure 1]. His BCVA was 6/9, N6, intraocular pressure was 22 mmHg with normal reacting pupil, and fundus in the left eye, while the right eye was unremarkable. CT angiography showed immediate enhancement of the left cavernous sinus with grossly dilated superior ophthalmic vein suggesting possibility of a carotico-cavernous fistula [Figure 2] without any bony fractures on the left side. Digital subtraction angiography was performed by a neurointerventional radiologist, which demonstrated a high flow-direct carotico-cavernous fistula (Type A) that was subsequently successfully treated with coil embolization procedure [Figure 3]. His symptoms resolved completely within 2 weeks of intervention [Figure 4].
Figure 1: At presentation, external (a) and worms' eye view (b) showing axial proptosis with slit-lamp photographs showing dilated episcleral vessels (c and d)

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Figure 2: Computed tomography (CT) angiography, axial (a) and coronal (b) sections showing gross dilatation of the left superior ophthalmic vein (blue arrowhead); enhancement of the left-sided cavernous sinus (yellow arrow) suggesting possible carotico-cavernous fistula (CCF) (c); 3-D reconstruction showing the left-sided direct CCF

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Figure 3: Digital subtraction angiography (DSA), preoperative left internal carotid artery (ICA) angiogram (a and c) showing direct CCF (yellow arrow) with grossly dilated superior ophthalmic vein (blue arrowhead); postembolization vertebral angiogram showing good collateral circulation (b and d)

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Figure 4: Postembolization, external (a) and worms' eye view (b) showing the complete resolution of proptosis as compared to Figure 1; slit-lamp photographs showing normal conjunctival and episcleral vessels (c and d)

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  Discussion Top


Craniofacial trauma is a major cause of CCF. When present, an early detection and treatment of CCF is essential to preserve visual acuity and avoid multiple cranial nerve palsies.[1] Carotico-cavernous fistula contralateral to the side of maxillofacial injuries is rarely reported.[2] Optimal treatment for direct CCF involves closure of abnormal arteriovenous communication and preservation of internal carotid artery patency. The techniques utilized by interventional radiologist include coil embolization, balloon occlusion of fistula, or covered stent grafts.[3],[4] A timely and successful occlusion of fistula can lead to resolution of proptosis, diplopia, and raised episcleral venous pressure.[4] The role of an ophthalmologist in early detection of CCF is to be emphasized.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yu SS, Lee SH, Shin HW, Cho PD. Traumatic carotid-cavernous sinus fistula in a patient with facial bone fractures. Arch Plast Surg 2015;42:791-3.  Back to cited text no. 1
    
2.
Shim HS, Kang KJ, Choi HJ, Jeong YJ, Byeon JH. Delayed contralateral traumatic carotid cavernous fistula after craniomaxillofacial fractures. Arch Craniofac Surg 2019;20:44-7.  Back to cited text no. 2
    
3.
Schutz P, Bosnjakovic P, Abulhasan YB, AI-Sheikh T. Traumatic carotid-cavernous fistula in a multiple facial fractures patient: Case report and literature review. Dent Traumatol 2014;30:488-92.  Back to cited text no. 3
    
4.
Chi CT, Nguyen D, Duc VT, Chau HH, Son VT. Direct traumatic carotid cavernous fistula: Angiographic classification and treatment strategies study of 172 cases. Interv Neuroradiol 2014;20:461-75.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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