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      Direct carotid-cavernous fistula: an atypical presentation

      case-report

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          Abstract

          Posttraumatic carotid-cavernous fistula (CCF) is a very rare complication that can occur in patients with craniomaxillofacial trauma. It is defined by abnormal communication between arteries and veins located in the cavernous sinus. CCFs can be divided into two groups: direct, which are usually post traumatic and classically with a high flow and acute onset of symptoms. On the other hand, indirect CCFs are in the most of cases idiopathic and typically insidious of onset. The aim of the present case report is to describe an atypical presentation of direct CCF characterized by the insidious onset of symptoms with the goal to think about this rare complication and so not to delay the treatment which is an emergency in this case.

          Most cited references14

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          Classification and treatment of spontaneous carotid-cavernous sinus fistulas.

          D L Barrow, R H Spector, I F Braun … (1985)
          An anatomical-angiographic classification for carotid-cavernous sinus fistulas is introduced and a series of 14 patients with spontaneous carotid-cavernous sinus fistulas is reviewed to illustrate the usefulness of such a classification for patient evaluation and treatment. Fistulas are divided into four types: Type A are direct high-flow shunts between the internal carotid artery and the cavernous sinus; Type B are dural shunts between meningeal branches of the internal carotid artery and the cavernous sinus; Type C are dural shunts between meningeal branches of the external carotid artery and the cavernous sinus; and Type D are dural shunts between meningeal branches of both the internal and external carotid arteries and the cavernous sinus. The anatomy, clinical manifestations, angiographic evaluation, indications for therapy, and therapeutic options for spontaneous carotid-cavernous sinus fistulas are discussed.
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            Carotid-cavernous fistulas.

            Jason Ellis, Hannah Goldstein, E Connolly … (2012)
            Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.
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              Treatment of carotid cavernous fistulas.

              Sameer Ansari, J Gemmete, Aditya Pandey … (2009)
              The treatment of a carotid cavernous fistula (CCF) depends on the severity of the clinical symptoms, its angiographic characteristics, and the risk it presents for intracranial hemorrhage. In most instances, endovascular treatment is preferred.High-flow direct CCFs usually are traumatic or are caused by rupture of a cavernous aneurysm into the sinus, but a small percentage can be spontaneous. They usually present with sudden development of a clinical triad: exophthalmos, bruit, and conjunctival chemosis. All direct CCFs should receive treatment, because they carry a high probability of intracranial hemorrhage or neurologic deterioration.Low-flow indirect or dural CCFs, either incidental or with minimal symptoms, are not associated with significant risk of intracranial hemorrhage. The accepted practice is to treat ocular symptoms conservatively with medical management or manual carotid compression. If the patient cannot tolerate the symptoms, or if signs of ocular morbidity occur, endovascular treatment is offered.The first treatment option should be endovascular embolization with a combination of detachable balloons, coils, stents, or liquid embolic agents. The procedure can be performed from either an arterial or venous approach. Use of these materials and techniques can yield a high cure rate with minimal complications.If the patient is not amenable to embolization or if the embolization fails, then surgery (surgical ligation of the internal carotid artery or packing of the cavernous sinus) should be offered.Stereotactic radiosurgery may be an elective treatment for low-flow CCFs, but it has no role in the treatment of high-flow CCFs.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Pan Afr Med J
                Journal ID (iso-abbrev): Pan Afr Med J
                Journal ID (publisher-id): PAMJ
                Title: The Pan African Medical Journal
                Publisher: The African Field Epidemiology Network
                ISSN (Electronic): 1937-8688
                Publication date (Electronic): 18 December 2019
                Publication date Collection: 2019
                Volume: 34
                Electronic Location Identifier: 204
                Affiliations
                [1 ]Department of Ophthalmology, Military Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco
                [2 ]Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco
                Author notes
                [& ]Corresponding author: Yousra Ajhoun, Department of Ophthalmology, Military Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco
                Article
                Publisher ID: PAMJ-34-204
                DOI: 10.11604/pamj.2019.34.204.19445
                PMC ID: 7060914
                SO-VID: 12c1ce63-b7ba-4efe-9ea5-162bfa0219ec
                Copyright © © Yousra Ajhoun et al.
                License:

                The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 12 June 2019
                Date accepted : 04 December 2019
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Medicine
                Keywords: direct carotid-cavernous fistula,insidious onset,craniofacial trauma
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: direct carotid-cavernous fistula, insidious onset, craniofacial trauma

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