Spontaneous Resolution Of Direct Carotid-cavernous Fistulas: Case Series And Literature Review
Iampreechakul, P., Tirakotai, W., Tanpun, A., Wattanasen, Y., Lertbusayanukul, P., & Siriwimonmas, S. (2019). Spontaneous resolution of direct carotid-cavernous fistulas: case series and literature review. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences, 25(1), 71–89. https://doi.org/10.1177/1591019918800220
View Original Source →Abstract
Spontaneous regression of direct carotid-cavernous fistulas (CCFs) is extremely rare. Most of the patients with direct CCFs are usually treated using endovascular techniques. Spontaneous obliteration of the direct fistulas probably results from thrombosis of the venous drainage and/or cavernous sinus. We report spontaneous closure of nine direct CCFs in nine patients. From literature review, we found another 37 patients with 43 fistulas due to spontaneous obliteration of bilateral lesions in six cases. There was no spontaneous closure in large-sized fistula. The factors associated with spontaneous thrombosis of the fistulas may be low-flow and small-sized fistula, hypotension, severe ocular manifestations, dissections or spasm of carotid artery, and increased intracranial pressure. Spontaneous healing of direct traumatic CCFs should be confirmed with cerebral angiography. Conservative treatment of direct CCFs should be carefully restricted in patients with normal vision or minimal visual impairment, and the patients must be monitored closely for any changes in visual function. Prompt endovascular treatment for complete obliteration of the fistula should be performed in patients with rapidly progressive visual loss. Venous thrombosis can still effect vision and rerouting towards cortical veins remains a concern. Because spontaneous resolution cannot be reliably predicted, the fistula then should be treated rather than waiting for spontaneous thrombosis.
Case Details
Disease Location
Brain (carotid-cavernous fistula)
Personal Characteristics
48-year-old man
Clinical Characteristics
Involved in a motor vehicle accident and sustained a severe head injury. A CT scan of the head showed bilateral subdural hematoma of the frontal lobes and right parietal contusion. Bilateral frontal craniotomies were performed. A few days later after trauma, he developed right proptosis, redness of the right eye, and audible bruit. Four months later, the patient went to another hospital and was diagnosed with secondary glaucoma of the right eye suspected from right traumatic ccf. His vision gradually deteriorated. Cerebral angiography was performed under local anesthesia, and revealed a direct ccf from the lateral aspect of the posterior genu of the right cavernous ica. After finishing the procedure, the blood pressure of the patient rapidly dropped to 40/0 mmhg. Fluid resuscitation, adrenaline injection, and intravenous hydrocortisone were required to increase his blood pressure to 90/50 mmhg over the next 15 minutes. Diluted dopamine (1:1) was continuously used to maintain blood pressure more than 90/ 60mmhg for another six hours.
Remission Characteristics
On the following day, redness of the eye and bruit entirely disappeared. MRI and magnetic resonance angiography (mra) one month later revealed a residual prominent right sov with minimal protrusion of the right glove. Ophthalmic examination revealed that the secondary glaucoma resolved, and his vision returned to normal. Seven years later, repeated MRI and mra confirmed disappearance of the direct ccf with a tiny pseudoaneurysm at the same location of the prior fistula
Treatment & Mechanisms
Proposed Remission Mechanisms
Combined effects of venous stasis and damaged surrounding tissues, leading to thrombosis of the cavern- ous sinus and/or venous drainage.
Clinical Treatment
Bilateral frontal craniotomies