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Case report
peer-reviewed

Superior Ophthalmic Vein Access for Embolization of an Indirect Carotid Cavernous Fistula



Abstract

Carotid cavernous fistulae (CCF) are defined as abnormal connections between the carotid circulation and cavernous sinus. CCFs can be categorized as being direct or indirect. Direct CCFs are usually associated with trauma, whereas indirect CCFs are associated with revascularization following cavernous sinus thrombosis. We present a case of a 53-year-old male who presented with tinnitus, proptosis, conjunctivitis, and blurry vision. The patient had a recent endovascular transvenous embolization that was only partially successful, with a residual carotid cavernous fistula draining to the left superior ophthalmic vein and multiple cortical veins. A physical examination of the patient showed elevated intraocular pressures bilaterally. The patient had a high-flow indirect carotid cavernous fistula with bilateral superior ophthalmic vein (SOV) and retrograde cortical vein drainage. The SOV was punctured with a micropuncture needle and was used to successfully gain access to the cavernous sinus. Multiple coils were placed in the posterior aspect of the sinus until there was complete occlusion of venous flow. Coils were packed up to the posterior aspect of the orbit near the junction of the cavernous sinus with the SOV, and the embolization was successful. Indirect CCFs have gradual onset and are usually low-flow. Low-flow CCFs might improve with medical management. Some CCFs may cause ocular manifestations and can be symptomatically managed with prism therapy or ocular patching for diplopia, lubrication for keratopathy, or topical agents for elevated intraocular pressures. However, patients presenting with persistent ocular morbidity may require surgical or endovascular intervention.



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Case report
peer-reviewed

Superior Ophthalmic Vein Access for Embolization of an Indirect Carotid Cavernous Fistula


Author Information

Ali S. Haider

Texas A&M College of Medicine

Health Science Center, Scott & White Clinic

Prabhat Garg

Texas A&M College of Medicine

Dean Leonard Corresponding Author

Texas A&M College of Medicine

Tijani Osumah

School of Medicine, Ross University

Umair Khan

School of Medicine, St. Georges University

Steven Vayalumkal

School of Medicine, St. George's University

Lyndon K. Lee

Texas A&M College of Medicine

Phu Nguyen

Texas A&M College of Medicine

Grant Gilliland

Texas A&m College of Medicine, Baylor University Medical Center

Kennith F. Layton

Department of Radiology, Baylor University Medical Center


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: The authors have declared that no conflicts of interest exist.


Case report
peer-reviewed

Superior Ophthalmic Vein Access for Embolization of an Indirect Carotid Cavernous Fistula


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Case report
peer-reviewed

Superior Ophthalmic Vein Access for Embolization of an Indirect Carotid Cavernous Fistula

  • Author Information
    Ali S. Haider

    Texas A&M College of Medicine

    Health Science Center, Scott & White Clinic

    Prabhat Garg

    Texas A&M College of Medicine

    Dean Leonard Corresponding Author

    Texas A&M College of Medicine

    Tijani Osumah

    School of Medicine, Ross University

    Umair Khan

    School of Medicine, St. Georges University

    Steven Vayalumkal

    School of Medicine, St. George's University

    Lyndon K. Lee

    Texas A&M College of Medicine

    Phu Nguyen

    Texas A&M College of Medicine

    Grant Gilliland

    Texas A&m College of Medicine, Baylor University Medical Center

    Kennith F. Layton

    Department of Radiology, Baylor University Medical Center


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: The authors have declared that no conflicts of interest exist.

    Acknowledgements


    Article Information

    Published: September 01, 2017

    DOI

    10.7759/cureus.1639

    Cite this article as:

    Haider A S, Garg P, Leonard D, et al. (September 01, 2017) Superior Ophthalmic Vein Access for Embolization of an Indirect Carotid Cavernous Fistula. Cureus 9(9): e1639. doi:10.7759/cureus.1639

    Publication history

    Received by Cureus: July 31, 2017
    Peer review began: August 21, 2017
    Peer review concluded: August 22, 2017
    Published: September 01, 2017

    Copyright

    © Copyright 2017
    Haider et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    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 author and source are credited.

Abstract

Carotid cavernous fistulae (CCF) are defined as abnormal connections between the carotid circulation and cavernous sinus. CCFs can be categorized as being direct or indirect. Direct CCFs are usually associated with trauma, whereas indirect CCFs are associated with revascularization following cavernous sinus thrombosis. We present a case of a 53-year-old male who presented with tinnitus, proptosis, conjunctivitis, and blurry vision. The patient had a recent endovascular transvenous embolization that was only partially successful, with a residual carotid cavernous fistula draining to the left superior ophthalmic vein and multiple cortical veins. A physical examination of the patient showed elevated intraocular pressures bilaterally. The patient had a high-flow indirect carotid cavernous fistula with bilateral superior ophthalmic vein (SOV) and retrograde cortical vein drainage. The SOV was punctured with a micropuncture needle and was used to successfully gain access to the cavernous sinus. Multiple coils were placed in the posterior aspect of the sinus until there was complete occlusion of venous flow. Coils were packed up to the posterior aspect of the orbit near the junction of the cavernous sinus with the SOV, and the embolization was successful. Indirect CCFs have gradual onset and are usually low-flow. Low-flow CCFs might improve with medical management. Some CCFs may cause ocular manifestations and can be symptomatically managed with prism therapy or ocular patching for diplopia, lubrication for keratopathy, or topical agents for elevated intraocular pressures. However, patients presenting with persistent ocular morbidity may require surgical or endovascular intervention.



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Create a free account to continue reading this article.

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Ali S. Haider

Texas A&M College of Medicine

Prabhat Garg

Texas A&M College of Medicine

Dean Leonard

Texas A&M College of Medicine

For correspondence:
dleonard1@medicine.tamhsc.edu

Tijani Osumah, Medical Student

School of Medicine, Ross University

Umair Khan, Medical Student

School of Medicine, St. Georges University

Steven Vayalumkal

School of Medicine, St. George's University

Lyndon K. Lee

Texas A&M College of Medicine

Phu Nguyen

Texas A&M College of Medicine

Grant Gilliland

Texas A&m College of Medicine, Baylor University Medical Center

Kennith F. Layton

Department of Radiology, Baylor University Medical Center

Ali S. Haider

Texas A&M College of Medicine

Prabhat Garg

Texas A&M College of Medicine

Dean Leonard

Texas A&M College of Medicine

For correspondence:
dleonard1@medicine.tamhsc.edu

Tijani Osumah, Medical Student

School of Medicine, Ross University

Umair Khan, Medical Student

School of Medicine, St. Georges University

Steven Vayalumkal

School of Medicine, St. George's University

Lyndon K. Lee

Texas A&M College of Medicine

Phu Nguyen

Texas A&M College of Medicine

Grant Gilliland

Texas A&m College of Medicine, Baylor University Medical Center

Kennith F. Layton

Department of Radiology, Baylor University Medical Center