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Carotid cavernous fistula after minimal facial trauma
Carotid cavernous fistula after minimal facial trauma Report of a case Gregory J. Keiser, DMD,O Andrew Zeidman, DDS,b and Bernard D. Gold, DMD,’ Brooklyn and New York, N.Y. KINGS COUNTY HOSPITAL
CENTER
AND DOWNSTATE
MEDICAL
CENTER
The carotid cavernous fistula has historically been associated with extensive facial trauma as a result of direct or indirect forces. Most fistulas of traumatic origin develop as a result of a fracture through the base of the skull, which produces a force causing laceration of the internal carotid artery in the region where it approximates the cavernous sinus. We report a case in which apparently minimal head trauma resulted in the development of a carotid cavernous fistula. The rather innocuous presentation of this complication requires particular attention by the caregiver in assessing the patient sustaining maxillofacial trauma. (ORAL SURC ORAL MED ORAL PATHOL 1991;71:549-51)
T
he cavernous sinusesare paired vascular channels between the dura mater and periosteum that form a reticulating network. Becauseof their proximity with other vascular and neural structures, any pathologic changesinvolving them may affect any or all of these adjacent structures. lb4This intimate anatomic relationship provides the basis for the development of the carotid cavernous fistula. CASE REPORT
On Dec. 12, 1986, a 28-year-old black man was seen at the Kings County Hospital Center emergency room with “double vision” and an increasingly painful left-sided headache, 2 weeksafter blunt trauma to the left side of his face. In addition, the patient reported a pulsation over the left eye and that the eye appeared “crooked” 2 days before presentation. Physical examination revealed a minimally palpable step defect over the left zygomatic arch. Mild periorbital edema and ecchymosis,slight subconjunctival hemorrhage,chemosis, and proptosis of the left eye were present. In addition, he had profound orbital restriction in the left lateral gaze, suggesting involvement of the sixth cranial nerve (Fig. 1). Auscultation of the left temporal and frontal areasrevealed
aFormerly Chief Resident, Oral and Maxillofacial Surgery, Kings County Hospital Center and Downstate Medical Center, Brooklyn; now in private practice, Morristown, N.J. bin private ‘practice, New York. CDirector, Oral and Maxillofacial Surgery, Kings County Hospital Center and Downstate Medical Center, Brooklyn. 7/12/19430
Fig.
1.
Patient unable to abduct left eye on left lateral
gaze.
a bruit, which was best appreciated in the supraorbital region. The pupils of both eyes were equal in size (3 mm), round, and reactive to light. The patient’s visual acuity was within normal limits. The roentgenographic survey revealed only a minimally depressedfracture of the left zygomatic arch. On further ophthalmologic evaluation a marked increase in the left intraocular pressurewas noted (22 mm Hg; normal 10 mm Hg). The patient had full range of motion of the right eye but was unable to abduct the left eye past the midline. Findings of the funduscopic examination were essentially normal, with the exception of questionable superotemporal retinal edema of the left eye. No signs of optic 549
550
Keiser, Zeidman, and Gold
OR
E rpanded
ORAL PATHOI May 1991
Hrmatoma
CerebralCsculahon -
Ophlhalmlc
Artery
Oph:halmrc Cavernous Postec0 E xlernal
Vems Sws Vetns
Carat
Fig. 2. Computed tomographic scan revealing carotid cavernous fistula with contrast filling left ophthalmic vein (arrow}.
nerve damagewere apparent; however, a restrictive palsy of the sixth cranial nerve was evident. Precontrast and postcontrast orbital computed tomographic scans with coronal and axial views were obtained and demonstrated prominent intraocular muscles and a tortuous and dilated superior ophthalmic vein with evidence of the formation of a carotid cavernous fistula (Fig. 2). A neurosurgical evaluation was obtained, and the treatment modality that was deemedmost acceptable, occlusion of the fistula with a detachable balloon, was proposed(Fig. 3). Before the use of a detachable balloon catheter, surgical treatment of this entity was done by trapping the fistula with muscle embolization. Although operative intervention is usually recommended, the indications must be appropriately weighed against the potential complications; namely, total carotid occlusion and visual impairment. Unfortunately, in this particular casethe patient refused further diagnostic or surgical manipulation and was discharged. DISCUSSION
The carotid cavernous fistula may evolve spontaneously as a result of a dural arteriovenous malformation; however, direct or indirect trauma with a resultant tear in the muscular wall of the internal carotid artery and bleeding into the sinus is the cause in the majority of cases.” *, 5 When a carotid cavernous fistula occurs, symptoms associatedwith changesin blood flow are manifested.3 Patients may have the following: exophthalmos; chemosis; extraocular palsies; headache; ocular discomfort; or a noise heard by the patient, synchronous with the pulse.2 The pulsatile headache is often the most disturbing feature to the patient. Visual complaints such as diplopia and blurred vision are also common.‘?3 Sequential development of signs and
l-l Fig. 3. Schematic of vascular systemwith carotid artery: Cavernous sinus fistula treated by balloon occlusion. From Harris AE, McMenamin G. Arch Otolaryngol 1984;llO: 623.
symptoms occur with regularity. Diplopia, which is usually the result of cranial nerve palsy, is often the first subjective symptom. ‘32This symptom is most often related to the engorgement of the nearby ophthalmic veins, which results in the compression of the abducent nerve.3 Proptosis is also due to the retrograde flow of blood into the ophthalmic veins. Extrusion of the eye may be as much as 8 to 10 rnrn.lw3Pupillary dilation usually results from parasympathetic loss. In addition, if the arterial supply is compromised as a result of the shunting of blood, visual acuity may be affected in one or both eyes. The major threat to vision is probably causedby hypoxia. The lowered arterial pressure and concomitant increased venous pressure reduce the ocular perfusion pressure. This visual damage, even if it were to occur, may be irreversible evenwith successfultreatment of the fistula.6 In the evaluation of extraocular muscular motion, most often the limitation of the affected eye in lateral gaze is noted. As previously mentioned, the abducent nerve is most often affected becauseof its medial location, which predisposesit to receive the compressive forces. Crarial nerves III and IV and the ophthalmic division of cranial nerve V may becomeinvolved as the lesion progresses. Additionally, the contralateral aspect of the eye may be involved becauseof the intersinus communication. *97 Although treatment of the carotid cavernousfistula
Volume 7 1 Number 5
Carotid cavernous jistula after minimal facial trauma
is not in the scope of the oral and maxillofacial surgeon, an understanding of the modalities available to the neurosurgeon is valuable. Indications for surgical intervention include preservation of vision, elimination of a bruit, intolerable pain, and cosmetic restoration. Before the use of present catheter techniques, other means of surgical correction included muscle embolization (involving a craniotomy procedure and occlusion of the internal carotid artery proximal to the ophthalmic artery), carotid ligation, and the use of sclerosing agents.7-9 During the past few years a number of catheterization techniques have been employed to obliterate the fistula, originally by occluding the internal carotid artery by the insertion of a balloon catheter, and most recently by occluding the fistula itself with a detachable balloon without obstruction of the internal carotid blood flo~.‘~-** The carotid cavernous fistula, although a relatively rare entity related to maxillofacial trauma, must be considered by the oral and maxillofacial surgeon in patient assessment.Its gradual evolution necessitates careful scrutiny by the examining doctor and emphasizes the importance of the patient’s chief complaint, which may not necessarily correspond to initial clinical findings.
2. Ojemann RG, Croswell RM. Carotid cavernous fistula. In:
Surgical management of cerebrovascular disease. Baltimore: Williams & Wilkins, 1983. Harris AE, McMenamin PG. Carotid artery-cavernous sinus fistula. Arch Otolaryngol 1984;) 10:618-23. Moore L. Clinically oriented anatomy. Baltimore: Williams & Wilkins, 1980:929-30. Yosom BM. Formation of an arteriovenous fistula (AVF). In: Angiography in trauma-a work atlas. Philadelphia: WB Saunders, 1981. 6. Sanders MD, Hoyt WF. Hypoxia ocular sequelae of carotid cavernous fistula: study of the causesof visual failure before and after neurosurgical treatment in a series of 25 cases.Br J Ophthalmol 1969;53:82-97. 7. Day AL, Rhoton AL Jr. Aneurysms and the arteriovenous fistula of the intracavernous carotid artery and its branches. In: Youmas JR, ed. Neurological surgery. 2nd ed. Philadelphia: W B Saunders, 1982:1764-81. 8. ParsonsTC, Guller EJ, Wolff HG, et al. Cerebral angiography in carotid cavernous communication. Neurology 1954;4: 353-4. 9. Brooks B. In discussion: Noland L, Taylor AS. South Surg
Assoc 1931;43:176. 10. Peterson EW. Electrically induced thrombosis of the cavernous sinus in the treatment of carotid cavernous fistula [Scientific exhibit]. Meeting of the American Association of Neurologic Surgeons, April 1969, Cleveland. 11. Parkinson D. Carotid cavernous fistula: direct repair with preservation of the carotid artery: technical note. J Neurosurg 1973;38:99-106. 12. Prolo DJ, Burres KP, Hanberry JW. Balloon occlusion of carotid cavernous fistula: introduction of a new catheter. Surg Neurol 1977;7:209-14. Reprint requests to:
REFERENCES
1. Niamtu J III, Campbell RL. Carotid cavernous fistula. J Oral Maxillofac Surg 1982;40:52-6.
55 I
Gregory J. Keiser, DMD Morristown Oral & Maxillofacial Surgery Associates 290 Madison Ave. Morristown, NJ 07960
CENTER
AND DOWNSTATE
MEDICAL
CENTER
The carotid cavernous fistula has historically been associated with extensive facial trauma as a result of direct or indirect forces. Most fistulas of traumatic origin develop as a result of a fracture through the base of the skull, which produces a force causing laceration of the internal carotid artery in the region where it approximates the cavernous sinus. We report a case in which apparently minimal head trauma resulted in the development of a carotid cavernous fistula. The rather innocuous presentation of this complication requires particular attention by the caregiver in assessing the patient sustaining maxillofacial trauma. (ORAL SURC ORAL MED ORAL PATHOL 1991;71:549-51)
T
he cavernous sinusesare paired vascular channels between the dura mater and periosteum that form a reticulating network. Becauseof their proximity with other vascular and neural structures, any pathologic changesinvolving them may affect any or all of these adjacent structures. lb4This intimate anatomic relationship provides the basis for the development of the carotid cavernous fistula. CASE REPORT
On Dec. 12, 1986, a 28-year-old black man was seen at the Kings County Hospital Center emergency room with “double vision” and an increasingly painful left-sided headache, 2 weeksafter blunt trauma to the left side of his face. In addition, the patient reported a pulsation over the left eye and that the eye appeared “crooked” 2 days before presentation. Physical examination revealed a minimally palpable step defect over the left zygomatic arch. Mild periorbital edema and ecchymosis,slight subconjunctival hemorrhage,chemosis, and proptosis of the left eye were present. In addition, he had profound orbital restriction in the left lateral gaze, suggesting involvement of the sixth cranial nerve (Fig. 1). Auscultation of the left temporal and frontal areasrevealed
aFormerly Chief Resident, Oral and Maxillofacial Surgery, Kings County Hospital Center and Downstate Medical Center, Brooklyn; now in private practice, Morristown, N.J. bin private ‘practice, New York. CDirector, Oral and Maxillofacial Surgery, Kings County Hospital Center and Downstate Medical Center, Brooklyn. 7/12/19430
Fig.
1.
Patient unable to abduct left eye on left lateral
gaze.
a bruit, which was best appreciated in the supraorbital region. The pupils of both eyes were equal in size (3 mm), round, and reactive to light. The patient’s visual acuity was within normal limits. The roentgenographic survey revealed only a minimally depressedfracture of the left zygomatic arch. On further ophthalmologic evaluation a marked increase in the left intraocular pressurewas noted (22 mm Hg; normal 10 mm Hg). The patient had full range of motion of the right eye but was unable to abduct the left eye past the midline. Findings of the funduscopic examination were essentially normal, with the exception of questionable superotemporal retinal edema of the left eye. No signs of optic 549
550
Keiser, Zeidman, and Gold
OR
E rpanded
ORAL PATHOI May 1991
Hrmatoma
CerebralCsculahon -
Ophlhalmlc
Artery
Oph:halmrc Cavernous Postec0 E xlernal
Vems Sws Vetns
Carat
Fig. 2. Computed tomographic scan revealing carotid cavernous fistula with contrast filling left ophthalmic vein (arrow}.
nerve damagewere apparent; however, a restrictive palsy of the sixth cranial nerve was evident. Precontrast and postcontrast orbital computed tomographic scans with coronal and axial views were obtained and demonstrated prominent intraocular muscles and a tortuous and dilated superior ophthalmic vein with evidence of the formation of a carotid cavernous fistula (Fig. 2). A neurosurgical evaluation was obtained, and the treatment modality that was deemedmost acceptable, occlusion of the fistula with a detachable balloon, was proposed(Fig. 3). Before the use of a detachable balloon catheter, surgical treatment of this entity was done by trapping the fistula with muscle embolization. Although operative intervention is usually recommended, the indications must be appropriately weighed against the potential complications; namely, total carotid occlusion and visual impairment. Unfortunately, in this particular casethe patient refused further diagnostic or surgical manipulation and was discharged. DISCUSSION
The carotid cavernous fistula may evolve spontaneously as a result of a dural arteriovenous malformation; however, direct or indirect trauma with a resultant tear in the muscular wall of the internal carotid artery and bleeding into the sinus is the cause in the majority of cases.” *, 5 When a carotid cavernous fistula occurs, symptoms associatedwith changesin blood flow are manifested.3 Patients may have the following: exophthalmos; chemosis; extraocular palsies; headache; ocular discomfort; or a noise heard by the patient, synchronous with the pulse.2 The pulsatile headache is often the most disturbing feature to the patient. Visual complaints such as diplopia and blurred vision are also common.‘?3 Sequential development of signs and
l-l Fig. 3. Schematic of vascular systemwith carotid artery: Cavernous sinus fistula treated by balloon occlusion. From Harris AE, McMenamin G. Arch Otolaryngol 1984;llO: 623.
symptoms occur with regularity. Diplopia, which is usually the result of cranial nerve palsy, is often the first subjective symptom. ‘32This symptom is most often related to the engorgement of the nearby ophthalmic veins, which results in the compression of the abducent nerve.3 Proptosis is also due to the retrograde flow of blood into the ophthalmic veins. Extrusion of the eye may be as much as 8 to 10 rnrn.lw3Pupillary dilation usually results from parasympathetic loss. In addition, if the arterial supply is compromised as a result of the shunting of blood, visual acuity may be affected in one or both eyes. The major threat to vision is probably causedby hypoxia. The lowered arterial pressure and concomitant increased venous pressure reduce the ocular perfusion pressure. This visual damage, even if it were to occur, may be irreversible evenwith successfultreatment of the fistula.6 In the evaluation of extraocular muscular motion, most often the limitation of the affected eye in lateral gaze is noted. As previously mentioned, the abducent nerve is most often affected becauseof its medial location, which predisposesit to receive the compressive forces. Crarial nerves III and IV and the ophthalmic division of cranial nerve V may becomeinvolved as the lesion progresses. Additionally, the contralateral aspect of the eye may be involved becauseof the intersinus communication. *97 Although treatment of the carotid cavernousfistula
Volume 7 1 Number 5
Carotid cavernous jistula after minimal facial trauma
is not in the scope of the oral and maxillofacial surgeon, an understanding of the modalities available to the neurosurgeon is valuable. Indications for surgical intervention include preservation of vision, elimination of a bruit, intolerable pain, and cosmetic restoration. Before the use of present catheter techniques, other means of surgical correction included muscle embolization (involving a craniotomy procedure and occlusion of the internal carotid artery proximal to the ophthalmic artery), carotid ligation, and the use of sclerosing agents.7-9 During the past few years a number of catheterization techniques have been employed to obliterate the fistula, originally by occluding the internal carotid artery by the insertion of a balloon catheter, and most recently by occluding the fistula itself with a detachable balloon without obstruction of the internal carotid blood flo~.‘~-** The carotid cavernous fistula, although a relatively rare entity related to maxillofacial trauma, must be considered by the oral and maxillofacial surgeon in patient assessment.Its gradual evolution necessitates careful scrutiny by the examining doctor and emphasizes the importance of the patient’s chief complaint, which may not necessarily correspond to initial clinical findings.
2. Ojemann RG, Croswell RM. Carotid cavernous fistula. In:
Surgical management of cerebrovascular disease. Baltimore: Williams & Wilkins, 1983. Harris AE, McMenamin PG. Carotid artery-cavernous sinus fistula. Arch Otolaryngol 1984;) 10:618-23. Moore L. Clinically oriented anatomy. Baltimore: Williams & Wilkins, 1980:929-30. Yosom BM. Formation of an arteriovenous fistula (AVF). In: Angiography in trauma-a work atlas. Philadelphia: WB Saunders, 1981. 6. Sanders MD, Hoyt WF. Hypoxia ocular sequelae of carotid cavernous fistula: study of the causesof visual failure before and after neurosurgical treatment in a series of 25 cases.Br J Ophthalmol 1969;53:82-97. 7. Day AL, Rhoton AL Jr. Aneurysms and the arteriovenous fistula of the intracavernous carotid artery and its branches. In: Youmas JR, ed. Neurological surgery. 2nd ed. Philadelphia: W B Saunders, 1982:1764-81. 8. ParsonsTC, Guller EJ, Wolff HG, et al. Cerebral angiography in carotid cavernous communication. Neurology 1954;4: 353-4. 9. Brooks B. In discussion: Noland L, Taylor AS. South Surg
Assoc 1931;43:176. 10. Peterson EW. Electrically induced thrombosis of the cavernous sinus in the treatment of carotid cavernous fistula [Scientific exhibit]. Meeting of the American Association of Neurologic Surgeons, April 1969, Cleveland. 11. Parkinson D. Carotid cavernous fistula: direct repair with preservation of the carotid artery: technical note. J Neurosurg 1973;38:99-106. 12. Prolo DJ, Burres KP, Hanberry JW. Balloon occlusion of carotid cavernous fistula: introduction of a new catheter. Surg Neurol 1977;7:209-14. Reprint requests to:
REFERENCES
1. Niamtu J III, Campbell RL. Carotid cavernous fistula. J Oral Maxillofac Surg 1982;40:52-6.
55 I
Gregory J. Keiser, DMD Morristown Oral & Maxillofacial Surgery Associates 290 Madison Ave. Morristown, NJ 07960