Diagnosis with Carotid Cavernous Fistula in Ophthalmologic Practice. Clinical case

Purpose: A clinical case of carotid cavernous fistula in ophthalmologic practice.

Methods. Patient M., 68 years old, came to the ophthalmologic department with complaints of decreased vision, redness, swelling of the right eye mucosa, and pain in the right parietal region. From the anamnesis morbi it is known that the above-mentioned complaints have been bothering for the last 3 months. She denies traumas. Аnamnesis vitae: Hypertensive disease for about 10 years, regularly takes hypotensive drugs. The polyclinic at the place of residence diagnosed chronic conjunctivitis of the right eye. The prescribed local treatment was followed, without positive effect. Standard ophthalmologic examination was performed; as a follow-up examination, duplex transcranial scanning of arteries and veins, duplex scanning of brachiocephalic arteries with color Doppler mapping of blood flow, MRI of the brain and orbit, CT angiography of cerebral vessels with contrast enhancement were prescribed. The patient was examined by a neurosurgeon and selective cerebral angiography of the brain with intravenous amplification was prescribed. The final diagnosis was made: Spontaneous carotid cavernous fistula on the right side. Endovascular embolization of vessels with occlusion of the indirect CSA of the right NSA basin with non-adhesive liquid composite material based on ethylene-vinyl alcohol copolymer (EVOH) was performed. Regression of ophthalmologic picture was noted in the postoperative period.

Results. Against the background of atherosclerosis of cerebral vessels, hypertension, the right external carotid artery basin (right middle meningeal artery) as well as meningeal branches of both internal carotid arteries with discharge into the right carotid-cavernous sinus and right ophthalmic vein was formed.

Conclusion. In spontaneous carotid cavernous fistula with small fistula size, the clinical picture of the disease may not have classical symptoms, causing difficulties in diagnosis and leading to inappropriate treatment tactics. To detect complex vascular disorders, it is important to use brain MRI in vascular mode as an additional method of investigation. Early diagnosis and targeted treatment are the key to a favorable outcome and successful rehabilitation of the patient.

1. Borden JA, Wu JK, Shucart WA. A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg. 1995;2:166–79. doi: 10.3171/jns.1995.82.2.0166.

2. Cognard C, Gobin YP, Pierot L. Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology. 1995;194:671–680. doi: 10.1148/radiology.194.3.7862961.

3. Steiger H‑J, Schmid‑Elsaesser R, Muacevic А, Brüuckmann H, Wowra B. Neurosurgery of arteriovenous malformations and fistulas: a multimodal approach. New York: Springer Verlag Wien; 2002. 476 р. doi: 10.1007/978‑3‑70916163‑0.

4. Pyatikop VA, Kotlyarevsky YuA, Sergienko YuG, Pshenichny AA, Voronen‑ ko KYu, Naboychenko AG. Use of endovascular techniques in the treatment of vascular pathology of the external carotid artery. Endovascular Neuroradiology. 2012;3– 4:18–23 (In Russ.).

5. Osborn AG, Salzman KL, Jhaveri MD, Volobuev DI (transl). Diagnostic Imaging: Brain. 3rd ed. Moscow: Izdatelstvo Panfilova; 2018. 1218 р. (In Russ.).

6. Gandhi D, Chen J, Pearl М, Huang J, Gemmete JJ, Kathuria S. Intracranial dural arteriovenous fistulas: classification, imaging findings, and treatment. AJNR Am J Neuroradiology. 2012;33:1007–10013. doi: 10.3174/ajnr.A2798.

7. Kalinin MN, Khasanova DR, Ibatullin MM, Kurado AT, Yausheva LM, Rakhimov ISh. The unusual cause of stroke: cerebral dural arteriovenous fistula. Neurology, Neuropsychiatry, Psychosomatics. 2015;7(4):37–41 (In Russ.). doi: 10.14412/20742711‑2015‑4‑37‑41.

8. Arkhangelskaya YaN, Serova NK, Yakovlev SB. Neuro‑ophthalmological symptoms of intracranial dural arteriovenous fistulas. Zh Vopr Neirokhir Im N N Burdenko. 2018;6(82):82–8 (In Russ.). doi: 10.17116/neiro20188206182.

9. Lopez Gomez P, Mato Manas D, Torres Diez E, Santos Jimenez C, Esteban Garcia J. Post‑traumatic carotidcavernous fistula. Pract Neurol. 2021;21(3):259–260. doi: 10.1136/practneurol‑2020‑002877.

10. Bolomatov NV, Germanovich VV, Matusov AV, Nikonova OV, Wheeler AG, Kuznetsov AN. Endovascular embolization of the carotid‑cavernous junction by detachable balloons. Bulletin of the National Medical and Surgical Center named after N.I. Pirogov. 2008;3(1):153–154 (In Russ.).

11. Barrow DL, Spector RH, Braun IF. Classification and treatment of spontaneous carotid‑cavernous sinus fistulas. J Neurosurg. 1985;62:248–256.

12. Gorner AT, Luong M. Carotid cavernous fistula presenting as common red eye. CJEM. 2021;23(1):123–125. doi: 10.1007/s43678‑020‑00030‑6.

13. Yang L, Tan QQ, Lan CJ, Liao X. Ophthalmic characteristics of carotid cavernous fistula: a case report. Int. J. Ophthalmol. 2021;14(6):952–954. doi: 10.18240/ijo.2021.06.25.

14. Israfilova GZ, Babushkin AE, Khismatullin RR. A clinical case of carotid‑cavernous fistula. Russian Ophthalmological Journal. 2024;17(1):113–118 (In Russ.). doi: 10.21516/2072‑0076‑2024‑17‑1‑113‑118.

15. Zhade SA, Pershin ME, Bely AI, Fedorchenko AN, Berestov VV, Orlov KYu, Tkachev VV, Muzlaev GG. Dural arteriovenous fistulas: two case reports and review. Innovative Medicine of Kuban. 2020;3:52–60 (In Russ.). doi: 10.35401/25000268‑2020‑19‑3‑52‑60.

16. De Aguiar GB, Jory M, Silva JM, Conti ML, Veiga JC. Advances in the endovascular treatment of direct carotid‑cavernous fistulas. Rev Assoc Med Bras. 2016;62(1):78–84.

17. Phan K, Xu J, Leung V. Orbital approaches for treatment of carotid cavernous fistulas: a systematic review. World Neurosurg. 2016;96:243–251. doi: 10.1016/j.wneu.2016.08.087.

18. Holland LJ, Ranzcr KM, Harrison JD, Brauchli D, Wong Y, Sullivan TJ. Endovascular treatment of carotid–cavernous sinus fistulas: ophthalmic and visual outcomes. Orbit. 2018;38(4):290–299. doi: 10.1080/01676830.2018.1544261.

19. Adam’s and Victor’s Principles of Neurology / Eds Allan H. Ropper, MD, Martin A. Samuels, MD, Joshua P. Klein, MD, PhD, Sashank Prasad, MD, 11th McGraw‑Hill Education, 2019. 1664 p. ISBN: 978‑0071842617

20. Atlas of CT Angiography / Eds Gratian Dragoslav Miclaus, Horia Ples. 2nd Springer Nature Switzerland. Cham, 2019. 455 p. ISBN: 978‑3‑030‑16095‑1

21. Cerebrovascular Diseases / Eds LR Caplan, J Biller, MC Leary. 2nd Elsevier. Philadelphia, 2017. 947 p. ISBN: 978‑0‑12‑803058‑5.

22. Diagnostic imaging. Brain / Eds A Osborn, KL Salzman, MD. Jhaveri. 3rd Elsevier. Philadelphia, 2016. 1213 p. ISBN: 978‑0‑323‑37754‑6.

23. Magnetic resonance imaging of brain and spine / Eds SW Atlas. 5th Walters Kluwer. Philadelphia, 2017. 2257 p. ISBN: 978‑1‑469‑87320‑6.

24. Osborn’s brain / Ed A Osborn. 2nd Elsevier. Philadelphia, 2017. 1372 p. ISBN: 978‑0323‑47776‑5.

25. Alderazi YJ, Dharmadhikari S, Haussen DC, Yavagal DR. Teaching NeuroImages: Reversible pontomesencephalic edema caused by traumatic carotid cavernous fistula. Neurology. 2014 Jul 8;83(2):e18. doi: 10.1212/WNL.0000000000000562.

26. Azzam DB, Cypen SG, Conger JR, Tao JP. Carotid‑Cavernous Sinus Fistula Masquerading as Thyroid Eye Disease. Cureus. 2021;13(4):e14261. doi: 10.7759/cureus.14261.

27. Ryu BU, Owji S, Pakravan M, Charoenkijkajorn C, Lee AG. Audible blink in carotid‑cavernous fistula. Can J Ophthalmol. 2023;58(1):e42–e44. doi: 10.1016/j.jcjo.2022.06.003.

28. Pakhirko IN, Ponomareva MN, Ponomareva YeYu, Aymurzina IA, Samodurov AI, Klokov IN. Diagnostics of carotid‑cavernous fistula in ophthalmological practice. point of view.Vostok‑Zapad. 2019;(3):116–118 (In Russ.). doi: 10.25276/2410‑12572019‑3‑116‑118.