Carotid-cavernous fistula: Difference between revisions
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==Background== | ==Background== | ||
*Fistula between carotid and cavernous sinus | *Fistula between carotid and cavernous sinus | ||
*Majority arise from trauma | |||
**Exact mechanism unclear/variable, may arise from small tear in internal carotid or branches due to basilar [[skull fracture]] (esp. through sphenoid), shear forces, or abrupt increases in intraluminal pressure when compressed due to neck flexion<ref>UpToDate</ref> | |||
*May also occur spontaneously, due to aneurysms, thrombosis, or weakening in arterial wall | |||
**Risk factors include [[connective tissue disease]] e.g. Ehler's Danlos | |||
=Clinical Features== | |||
* | *Onset typically abrupt within hours to few days after initial insult, but may present weeks after trauma | ||
*Symptoms due to arterialization of orbital veins | |||
*Pulsating exophthalmos/[[proptosis]] | |||
*Raised [[intraocular pressure]] | |||
*[[Eye pain]] (ocular and/or orbital), [[headache]] | |||
*[[Red eye|Chemosis]] | |||
*[[Diplopia]] or blurry vision | |||
*[[Abducens nerve palsy|CN VI palsy]] | |||
**Esotropia (eye moves inwards), [[diplopia]] | |||
*[[Third nerve palsy|CNIII palsy]] | |||
**Exotropia (eye moves laterally) | |||
**Ptosis | |||
**Pupillary dilation | |||
*Bruit (over eye or head) | |||
Possible complications include: | |||
*Acute angle [[glaucoma]], [[vitreous hemorrhage]], [[retinal detachment]] | |||
**Can lead to [[vision loss]] | |||
*[[ICH]], [[SAH]] (if fistula drains into cortical veins) | |||
*Severe [[epistaxis]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
*Conventional angio is gold standard, but can be seen on CT/CTA or MRI/MRA of head/orbits | |||
==Management== | ==Management== | ||
*5-10% close spontaneously<ref>Adams and Victor's Principles of Neurology, 10e</ref> remainder must be closed by interventional radiology (e.g. embolization) or surgically | |||
==Disposition== | ==Disposition== | ||
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==See Also== | ==See Also== | ||
*[[Red eye]], [[eye pain]] | |||
*[[Head trauma]] | |||
*[[Cranial nerve palsies]] | |||
==External Links== | ==External Links== | ||
Revision as of 21:28, 27 January 2019
Background
- Fistula between carotid and cavernous sinus
- Majority arise from trauma
- Exact mechanism unclear/variable, may arise from small tear in internal carotid or branches due to basilar skull fracture (esp. through sphenoid), shear forces, or abrupt increases in intraluminal pressure when compressed due to neck flexion[1]
- May also occur spontaneously, due to aneurysms, thrombosis, or weakening in arterial wall
- Risk factors include connective tissue disease e.g. Ehler's Danlos
Clinical Features=
- Onset typically abrupt within hours to few days after initial insult, but may present weeks after trauma
- Symptoms due to arterialization of orbital veins
- Pulsating exophthalmos/proptosis
- Raised intraocular pressure
- Eye pain (ocular and/or orbital), headache
- Chemosis
- Diplopia or blurry vision
- CN VI palsy
- Esotropia (eye moves inwards), diplopia
- CNIII palsy
- Exotropia (eye moves laterally)
- Ptosis
- Pupillary dilation
- Bruit (over eye or head)
Possible complications include:
- Acute angle glaucoma, vitreous hemorrhage, retinal detachment
- Can lead to vision loss
- ICH, SAH (if fistula drains into cortical veins)
- Severe epistaxis
Differential Diagnosis
Bilateral red eyes
- Painful
- Painless
Evaluation
- Conventional angio is gold standard, but can be seen on CT/CTA or MRI/MRA of head/orbits
Management
- 5-10% close spontaneously[2] remainder must be closed by interventional radiology (e.g. embolization) or surgically