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
40-year-old woman
Clinical Characteristics
Assaulted by being hit on her left ear without unconsciousness. A few days later, she developed mild redness and proptosis of the left eye with bruit. Two weeks later, her eye’s symptoms had rapidly worsened. CT scan showed an enlarged left sov, cavernous sinus, and protruding eyeball without any skull or orbital fracture. On ophthalmic examination, the left eye had proptosis, severe chemosis, lateral rectus palsy, and high intraocular pressure (iop). Visual acuity (va) was 20/20 in the right eye and counting fingers in the left eye. Secondary glaucoma from the ccf was medically treated by oral acetazolamide in combination with topical timolol. Cerebral angiography revealed a direct left ccf from the medial aspect of the posterior genu of the left cavernous ica, draining anteriorly through the sov and inferior ophthalmic veins (iovs), and posteriorly through the ips.
Remission Characteristics
While waiting for embolization, her symptoms gradually improved until disappearance of proptosis, chemosis, and bruit in the next one month. Repeated ophthalmologic examination revealed mild residual dilated episcleral veins, improvement of lateral rectus palsy, and normal iop. Va was 20/20 in both eyes. Six months later, cerebral angiography confirmed complete closure of the fistula with a residual small pseudoaneurysm
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
Acetazolamide in combination with topical timolol