Carotid cavernous fistula (CCF), also known as pulsatile proptosis, is the most common intracranial arteriovenous fistula. more than 80% are caused by trauma and less than 20% are spontaneous. Patients often visit the ophthalmology department for ocular symptoms and are misdiagnosed. A case of CCF was diagnosed and treated with intervention in our hospital in early 2002 and followed up for two years. Since no report was found in the literature in the Baotou area, we report the following: Pan Xiaoping, Department of Interventional Vascular Surgery, Wuhai People’s Hospital
General information: The patient was a 46-year-old female, diagnosed with “concussion and slipped vertebra of the 10th thoracic vertebra” after a car accident on January 8. A week later, she suddenly felt swelling of the left eye with hemilateral headache, rumbling sound in the ear, vision loss, and left eye abduction. The left common carotid artery was compressed and the intracranial murmur disappeared. A whole-brain angiogram was done electively, and it was seen that the left internal carotid artery was overflowing in the cavernous sinus, and the left internal carotid artery could also be visualized. The diagnosis of “carotid cavernous sinus fistula” was made. The 8F sheath was inserted using the Seldinger method, and the balloon was inserted into the cavernous sinus of the internal carotid artery using a balloon guide with a Magic BDPF cephalic tie No. 2, adjusted in position, and filled with 0.35 ml of Onepac contrast agent at a concentration of 180 mgI/ml, and the patient’s intracranial murmur disappeared and he felt a slight headache. The balloon was released and the tube was withdrawn 6 hours later. 4 weeks after rechecking the carotid cavernous sinus fistula was cured. The patient was followed up for two years with no significant discomfort.
Discussion: Since Cushing first proposed carotid cavernous sinus fistula in 1907, with the development of neurosurgery and imaging and interventional radiology, the diagnosis and treatment of CCF has made rapid progress. The cavernous sinuses are a pair of large venous sinuses located on either side of the pterygoid saddle, into which the internal carotid artery penetrates from the posterior end, the only place in the body where an artery passes through a venous structure. If the internal carotid artery itself or its branches within the cavernous sinus segment rupture, an abnormal arteriovenous communication with the cavernous sinuses is formed. In 96.4% of patients, there is pulsating proptosis, 100% have an intolerable intracranial continuous rumbling murmur, 100% have bulbar conjunctival edema and congestion, 44.4% have eyelid ectropion, 70.4% have varying degrees of limited eye movement, 73-89% have visual loss, and severe neurological dysfunction and subarachnoid hemorrhage can occur.
Among the imaging diagnostics, cerebral angiography is the decisive diagnosis of CCF. Selective whole brain angiography can reveal the site and size of the fistula, cerebral circulation compensation, whether there is total “steal”, the external carotid artery supply, the direction of venous drainage, and other cerebral artery variants or abnormalities that may affect treatment. The CT scan images may show diffuse thickening of the superior ophthalmic vein, protrusion of the eyeball, intraorbital muscle groups, increased parsaddle density, blurring of the eyeball rim, eyelid swelling, and bulbar conjunctival edema.
The treatment of CCF aims to protect vision, eliminate murmurs, retract proptosis, and prevent cerebral ischemia or hemorrhage. The ideal approach is to reliably close the fistula in the simplest way possible while maintaining patency of the internal carotid artery. Interventional embolization is currently the preferred treatment. It is usually a transarterial route, and embolization materials include detachable balloons, tungsten spring coils, Ivalon, and silk wire segments. The criteria for successful embolization are: the balloon is located inside the cavernous sinus and outside the internal carotid artery, the cavernous sinus is not in visualization, the internal carotid artery is flowing smoothly, and the vascular murmur disappears. If the occluded internal carotid artery cannot reach the fistula, the artery is tortuous and narrow, the catheter is difficult to insert, the fistula is small or multiple fistulas cannot be completely embolized, or the fistula artery embolization of the meningeal branch of the internal carotid artery and the cavernous sinus is difficult, the treatment can be done through the ophthalmic vein access. The main complications of interventional treatment of CCF are: occlusion of the internal carotid artery, cranial nerve palsy, pseudoaneurysm, premature balloon dislodgement, cerebral overperfusion of the affected hemisphere, and fistula recanalization. With the continuous improvement of intubation techniques, catheter fabrication and embolization materials, the probability of complications will be greatly reduced and the outcome of CCF treatment will become better.