Spontaneous thrombosis of post-traumatic direct carotid-cavernous fistula

Abstract

Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus, which is most commonly caused by trauma. Due to its high-flow nature and aggressive clinical course, spontaneous resolution of CCF is rare, making endovascular embolization necessary. This procedure aims to prevent potential vision loss, emphasizing the importance of timely intervention to preserve visual function. We report a case of Barrow type A carotid-cavernous fistula which resolved spontaneously. A 42-year-old male was referred to Emergency Room with a chief complaint of seizure 3 days before admission. The seizure was both arm stiff and jerking, the eyes gazing upward, bitten tongue, foamy mouth, no bed wetting. Meanwhile, the patient was unconscious during and after the seizure. Regarding the medical history, the patient experienced head trauma 8 months ago due to a traffic accident. Additionally, the patient reported symptoms of redness, swelling, double vision, and inability to look to the right eye. Initial cerebral angiography was performed, reporting a carotid-cavernous fistula of Barrow type A. Further endovascular treatment could not be carried out, but a second cerebral angiography was conducted after a year, demonstrating spontaneous thrombosis of the carotid-cavernous fistula of Barrow type A. CCF were classified by Barrow et al. into types A, B, C, and D. It has been proposed that spontaneous resolution of CCF Barrow type A may result from thrombosis of the cavernous sinus.

Keywords: Carotid-cavernous fistula; Embolization; Spontaneous resolution.

Fig. 1

Axial Head CT on April 13th 2021. without contrast (A), Axial Head CT on April 13th 2021 with contrast. (B) showing dilated right superior ophthalmic vein (White arrow).

Fig. 2

Cerebral angiography on May 24th, 2021 Right carotid angiogram showing traumatic carotid-cavernous fistula with dilated superior ophthalmic vein.

Fig. 3

Cerebral angiography on December 22th, 2021 after 7 months shows complete resolution of carotid cavernous fistula with preservation of internal carotid artery blood flow.