High index of suspicion: diagnosing a carotid-cavernous fistula

Abstract

A woman in her 70s presented with acute bilateral retro-orbital headache, diplopia, chemosis and eye swelling. Ophthalmology and neurology were consulted after detailed physical examination and diagnostic workup including laboratory analysis, imaging and lumbar puncture. The patient was diagnosed with non-specific orbital inflammation and was started on methylprednisolone and dorzolamide–timolol for intraocular hypertension. The patient’s condition improved slightly, but a week later, she developed subconjunctival haemorrhage in the right eye, which prompted investigation for a low-flow carotid-cavernous fistula. Digital subtraction angiography showed bilateral indirect carotid-cavernous fistula (Barrow type D). The patient underwent bilateral carotid-cavernous fistula embolisation. Her swelling improved considerably on day 1 after the procedure and her diplopia improved over the following weeks.

Fistulas Carótido Cavernosas (FCC). Lo que un oftalmólogo debe conocer: Revisión de casos sometidos a tratamiento endovascular en el Instituto de Neurocirugía Dr. Asenjo, Santiago, Chile

“…9,10 Por el contrario, se sugiere que el diagnóstico de fístula carótido cavernosa siempre debe ser un diferencial a considerar ante patologías oftalmológicas agudas, sobre todo considerando los síntomas principales que hemos mencionado. 11 El diagnóstico se confirmará con imágenes de cerebro, angioTC o angioRM de cerebro dependiendo de la disponibilidad. Una vez confirmado el diagnóstico el paciente debe ser derivado a un centro con capacidad de realización de angiografía cerebral, con el objetivo de documentar los vasos aferentes, drenaje venoso y clasificar el tipo de fístula, y planificar la terapia endovascular.…”