Direct carotid-cavernous fistula in a Filipino female presenting with simultaneous orbital/ocular, cavernous and cortical symptomatology without history of trauma: A case report

@#Carotid-cavernous fistula (CCF) is a rare and dangerous neurological disorder that arises due to an abnormal communication between the internal carotid artery (ICA) or the external carotid artery (ECA) and their branches and the cavernous sinus. It can either be a direct fistula (high-flow with acute symptoms) most commonly resulting from trauma (70-90%) or an indirect fistula (low-flow with insidious symptoms) secondary to hypertension, atherosclerosis and collagen vascular disorders. The shunting of arterial blood into the venous system leads to venous hypertension causing various clinical manifestations depending on the venous drainage patterns and the shunt flow. Increased anterior, posterior and superior venous drainage results to orbital/ocular, cavernous and cortical symptomatology, respectively. This paper aims to present a case of 58-year old Filipino female with a 2-day history of sudden, severe headache, vomiting and blurring of vision followed by decrease in sensorium and sudden proptosis and chemosis of the left eye. Patient had no co-morbidities, history of trauma, surgeries, facial skin infections or prior febrile illness. The left eye had exophthalmos, subconjunctival hyperemia, scleral edema/chemosis and ocular bruit. Neurologic examination showed a stuporous patient with multiple cranial nerve deficits (impaired direct and consensual pupillary reflex left, complete ptosis left, sluggish corneal reflex left, impaired oculocephalic reflex left), right hemiplegia and meningeal signs. Cranial Computed Tomography (CT) Angiogram revealed an acute parenchymal hemorrhage in the left frontotemporal lobe with subarachnoid component, with engorged left cavernous sinus and dilated left superior ophthalmic vein. Digital Subtraction Angiography (DSA) was done revealing a direct type of left carotid-cavernous fistula with massive ICA shunting to the cavernous sinus, superior ophthalmic vein and inferior petrosal sinus. The clinical and radiographic evidence were consistent with a Direct/Type A CCF. Unique in this case was a patient with no history of trauma presenting with simultaneous orbital/ocular, cavernous and cortical symptomatology – a clinical picture of CCF that has never been documented in any literature nor included in any classification system. The presence of all three symptomatology can be explained by a direct/highflow fistula that resulted to increased anterior, posterior and superior venous drainage as documented in the DSA. In addition, spontaneous intracranial hemorrhage in CCF is exceptionally rare and it is the most daunting symptomatology of this disease. With that, this specific case may pave the way to a new classification scheme and determine its corresponding treatment approach.

Ophthalmic complications of endoscopic sinus surgery / Complicações oftálmicas da cirurgia endoscópica dos seios nasais

Abstract Introduction: The proximity of the paranasal sinuses to the orbit and its contents allows the occurence of injuries in both primary or revision surgery. The majority of orbital complications are minor. The major complications are seen in 0.01-2.25% and some of them can be serious, leading to permanent dysfunction. Objective: The aim of this study was to determine the risk and type of ophthalmic complications among patients operated due to a chronic rhinosinusitis. Methods: This is a retrospective study of 1658 patients who underwent endoscopic sinus surgery for chronic rhinosinusitis with or without polyps or mucocele. Surgeries were performed under general anesthesia in all cases and consisted of polyps' removal, followed by middle metal antrostomy, partial or complete ethmoidectomy, frontal recess surgery and sphenoid surgery if necessary. The ophthalmic complications were classified according to type, frequency and clinical findings. Results: In our material 32.68% of the patients required revision surgery and only 10.1% had been previously operated in our Department. Overall complications occurred in 11 patients (0.66%). Minor complications were observed in 5 patients (0.3%) with the most frequent being periorbital ecchymosis with or without emphysema. Major complications were observed in one patient (0.06%) and were related to a lacrimal duct injury. Severe complications occurred in 5 cases (0.3%), with 2 cases and referred to a retroorbital hematoma, optic nerve injury (2 cases) and one case of extraocular muscle injury. Conclusions: Orbital complications of endoscopic nasal surgery are rare. The incidence of serious complications, causing permanent disabilities is less than 0.3%. The most important parameters responsible for complications are extension of the disease, previous endoscopic surgery and coexisting anticoagulant treatment.

Resumo Introdução: A proximidade dos seios paranasais à órbita e seu conteúdo tornam possível a ocorrência de lesões tanto na cirurgia primária como na de revisão. A maioria das complicações orbitais são menores. As maiores são observadas em 0,01%-2,25% e algumas delas podem ser graves levando a disfunção permanente. Objetivo: O objetivo deste estudo foi identificar o risco e o tipo de complicações oftalmológicas em pacientes operados devido a rinossinusite crônica. Método: Foi realizado um estudo retrospectivo com 1.658 pacientes submetidos a cirurgia endoscópica sinusal devido a rinossinusite crônica com ou sem pólipos ou mucocele. As cirurgias foram realizadas sob anestesia geral em todos os casos e consistiram de remoção de pólipos, seguida de antrostomia meatal média ou etmoidectomia parcial ou completa, cirurgia de recesso frontal e cirurgia de esfenoide se necessário. As complicações oftalmológicas foram classificadas de acordo com o tipo, frequência e achados clínicos. Resultados: Em nosso material 32,68% dos pacientes necessitaram de cirurgia de revisão e apenas 10,1% haviam sido anteriormente operados em nosso departamento. As complicações gerais ocorreram em 11 pacientes (0,66%). Complicações menores foram observadas em 5 pacientes (0,3%), sendo que a mais frequente foi equimose periorbital com ou sem enfisema. Complicações maiores foram observadas em um paciente (0,06%) e atribuída à lesão do ducto lacrimal. Complicações graves ocorreram em 5 casos (0,3%) e foram referidas como hematoma retrorbital (2 casos), lesão do nervo óptico (2 casos) e um caso de lesão muscular extraocular. Conclusões: As complicações orbitais da cirurgia endoscópica nasal são raras. A incidência de complicações graves que causam incapacidade permanente é de menos de 0,3%. Os parâmetros mais importantes responsáveis por complicações são extensão da doença, cirurgia endoscópica anterior e tratamento anticoagulante coexistente.