Carotid-Cavernous Fistulae : Figure 1 & 2

A 79-year-old woman with left-sided chemosis, proptosis, conjunctival arterialization, and visual impairment. (A) T1-weighted (TR 900/TE 30) MR image of the orbits demonstrates left-sided proptosis (white arrow) and asymmetrical prominence of the vessels within the left orbit (black arrows). Also note abnormal flow signal in the posterior aspect of the left cavernous sinus (arrowhead). (B)-(D) Digital subtraction arteriography of the internal carotid artery (early arterial phase (B) and venous phase (C) and external carotid artery (arterial phase [D]) demonstrates an indirect fistula of the left cavernous sinus (black arrows). (E) Although the inferior petrosal sinus was not visualized, careful microcatheter manipulation safely accessed the left cavernous sinus for transvenous coil occlusion of the fistula. (F) Digital subtraction arteriography of the left common carotid artery after embolization demonstrates complete angiographic cure. Bruit, proptosis, and chemosis resolved within the first 24 hours; cranial neuropathy resolved within 1 month.
 

24 year old woman developed painful redness and swelling of her left eye after she bumped her head on the steering wheel during a car accident. MRI brain scan shows protrusion of the left eye and abnormal blood flow in the cavernous sinus behind the left eye (top left image, white arrows). Cerebral arteriography in the lateral and frontal projections demonstrate rapid flow of blood from the carotid artery into the surrounding veins at the base of the skull due to a tear in the carotid artery at the time of the accident (top right images, black arrows). This is called a “direct” carotid-cavernous fistula and is most commonly due to trauma or, less commonly, a ruptured aneurysm. In this case, the patient was quickly cured by placement of a tiny balloon into the hole in the carotid artery, thus sealing the tear and allowing the artery to heal (bottom left image, black arrows). The patient’s signs and symptoms quickly subsided, and she made an uneventful recovery. Traumatic carotid cavernous fistulas are now less common due to the widespread availability of cars with air bags.