A Fel1, Z Szatmary2, N Sourour2, B Bodaghi1, P LeHoang1, V Touitou3. 1. Service d'ophtalmologie, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France. 2. Service de neuro-radiologie interventionnelle, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France. 3. Service d'ophtalmologie, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France. Electronic address: valerie.touitou@psl.aphp.fr.
Abstract
INTRODUCTION: Depending upon the type of communication between the internal carotid artery and the cavernous sinus, two types of carotid-cavernous fistulae can be distinguished: direct carotid-cavernous fistula (DCCF), for which diagnosis is usually easy because of the obvious signs of orbital congestion, and indirect carotid-cavernous fistula (ICCF) or dural fistula, with few symptoms, associated with a delay in diagnosis which can alter prognosis for function and even life. PURPOSE: The purpose of this study is to determine characteristic signs of both types of CCF and to study their correlation with the anatomical type of vessels involved on the angiogram. The prognosis for both types of fistula was also studied. METHOD: Retrospective single-center study, including patients with angiographically confirmed DCCF or ICCF. Demographic, clinical, and prognostic characteristics of these patients were analyzed and compared with the angiogram findings. RESULTS: Six patients (4 DCCF and 2 ICCF) were included in this study. Mean age at diagnosis was 62.7 years in the DCCF group and 62 years in the ICCF group. Mean time until diagnosis was 7 weeks in the DCCF group and 24 weeks in the ICCF group. Signs of orbital congestion were present in 100% of patients with DCCF and absent in all patients in the ICCF group. Mean proptosis was 3.5mm in the DCCF group and 0.5 in the ICCF group. All patients had an audible bruit on auscultation. The location of the bruit was orbital in all patients with DCCF, and pretragal or jugal in 50% of patients with ICCF. CONCLUSIONS: ICCF can impact mortality and are often underdiagnosed. The diagnostic delay observed in our study reflects the difficulties which persist in recognizing the clinical signs of this condition. ICCF must be suspected in the case of a history suggestive of CCF, even if the clinical examination appears normal. The presence of a bruit must be carefully sought, not only in the classical orbital location, but also in other facial locations as shown in our study. Our results demonstrate that there is indeed a good correlation between the site of the CCF, the location of the bruit, and the vessels involved.
INTRODUCTION: Depending upon the type of communication between the internal carotid artery and the cavernous sinus, two types of carotid-cavernous fistulae can be distinguished: direct carotid-cavernous fistula (DCCF), for which diagnosis is usually easy because of the obvious signs of orbital congestion, and indirect carotid-cavernous fistula (ICCF) or dural fistula, with few symptoms, associated with a delay in diagnosis which can alter prognosis for function and even life. PURPOSE: The purpose of this study is to determine characteristic signs of both types of CCF and to study their correlation with the anatomical type of vessels involved on the angiogram. The prognosis for both types of fistula was also studied. METHOD: Retrospective single-center study, including patients with angiographically confirmed DCCF or ICCF. Demographic, clinical, and prognostic characteristics of these patients were analyzed and compared with the angiogram findings. RESULTS: Six patients (4 DCCF and 2 ICCF) were included in this study. Mean age at diagnosis was 62.7 years in the DCCF group and 62 years in the ICCF group. Mean time until diagnosis was 7 weeks in the DCCF group and 24 weeks in the ICCF group. Signs of orbital congestion were present in 100% of patients with DCCF and absent in all patients in the ICCF group. Mean proptosis was 3.5mm in the DCCF group and 0.5 in the ICCF group. All patients had an audible bruit on auscultation. The location of the bruit was orbital in all patients with DCCF, and pretragal or jugal in 50% of patients with ICCF. CONCLUSIONS: ICCF can impact mortality and are often underdiagnosed. The diagnostic delay observed in our study reflects the difficulties which persist in recognizing the clinical signs of this condition. ICCF must be suspected in the case of a history suggestive of CCF, even if the clinical examination appears normal. The presence of a bruit must be carefully sought, not only in the classical orbital location, but also in other facial locations as shown in our study. Our results demonstrate that there is indeed a good correlation between the site of the CCF, the location of the bruit, and the vessels involved.