Case 21: traumatic carotid-cavernous fistula

posted: August 4, 1997

Resident: Bryan Payne, MD
Attending: Deepak Awasthi, MD and John Conners, MD (Neuroradiology)

CLINICAL PRESENTATION: This 77 year old white woman presented to the neurology service with a 2 month history of left eye proptosis, pain, chemosis- progressively worsening with accompanying difficulty moving the eye. Patient was involved in a fall after the patient's husband, while driving the car out of the driveway, hit the patient leading to direct left eye trauma. The patient denied any history of diabetes mellitus, thyroid disease, hypertension, or heart disease. Patient was in good medical condition.

EXAMINATION: pulse: 86; BP: 130/80; R: 22; afebrile. Patient was in mild distress from left orbital pain and tenderness. There was obvious proptosis and chemosis of the left eye. Extraocular movements were diminshed on lateral gaze in the left eye- otherwise all other extraocular movements were intact. Vision was 20/40 bilaterally.

Remainder of the cranial nerves were normal. Patient was awake, alert, oriented. There were no speech deficits. Motor, senosry, cerebellar exams were normal bilaterally. Gait was normal. Reflexes were 2+ symmetric. There were no pathological reflexes.

DIAGNOSTIC STUDIES: The cranial CT scan and MRI scan were suggestive of a left carotid- cavernous fistula. This lead to a cerebral angiogram (four vessel). The left common carotid view is shown below:

The carotid cavernous fistula is evident.

STEPS TAKEN AT LSU: Initially a balloon test occlusion (BTO) was performed with monitoring of the clincal exam and cerebral blood flow (SPECT). The patient passed the BTO with the balloon in the cervical ICA, petrous ICA and supraclinoid ICA.

At this point, neuroradiology attempted balloon occlusion of the fistula with the goal of preservation of the ICA. The balloon kept floating distally past the left posterior communicating artery- after repeated attempts at balloon occlusion, the neuroradiologist felt that such a procedure would place the patient's collateral circulation at risk. Thus, neurosurgery was consulted for intracranial occlusion of the ICA (proximal to the left ophthalmic artery). Through a standard left pterional craniotomy, the left supraclinoid ICA was approached. The anterior clinoid process was resected and the dural ring opened to allow optimum clip placement proximal to the left ophthalmic artery. This was accomplished. The postoperative cerebral angiogram (left common carotid and vertebral) was now done and, interestingly, the CCF was completed occluded by only one clip intracranially. The postoperative left common carotid angiogram is shown below:

red marker is on the left ophthalmic artery

On a later date another clip was placed on the cervical ICA (to prevent any recanalization proximally).

POSTOPERATIVE COURSE: Postoperative course was significant for expressive dysphasia which improved over several weeks. Postoperative SPECT study revealed a small area of diminished flow in the frontal operculum.

Comments and Questions about this interesting case are welcomed. Please e-mail: dawast@lsuhsc.edu

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