Comparison of ophthalmological symptoms and ultrasound data of the vessels of the brain and orbit in the diagnosis and treatment of direct carotidcavernous fistulas

Purpose of the study was to evaluate the role of ophthalmological and ultrasound examination (US) in the diagnosis and evaluation of the treatment efficiency of direct carotid-cavernous fistulas (DCCF).

Material and methods. Ten patients (7 men and 3 women) aged 19 to 65 years with DCCF were examined. All patients underwent a complete ophthalmological examination and US of the cerebral and orbital vessels before and after treatment.

Results. The diagnosis of DCCF was verified by selective cerebral angiography of the cerebral vessels, which is the gold standard in the examination of patients with DCCF. Traumatic DCCF was detected in 8 patients, spontaneous DCCF was detected in 2 patients. In all patients, ophthalmological examination revealed signs of impaired venous outflow from the eye and orbit. US revealed direct and indirect signs of DCCF. Angiographic examination was combined with endovascular intervention. Reconstructive surgeries were performed in 7 patients, and deconstructive surgeries were performed in 3 patients. In the early postoperative period, all patients showed varying degrees of reduction in congestion in the eye and orbit. According to US data after surgery, all patients showed no signs of functioning of DCCF, a decrease in the size of the superior ophthalmic vein and normalization of blood flow in it.

Conclusion. A high correlation was found between the results of ophthalmological and US examination in diagnosing the DCCF and in the early postoperative period. Ophthalmological symptoms allow diagnosing impaired venous outflow from the eye and orbit. US allows visualizing signs of the DCCF, determining hemodynamic characteristics of the anastomosis and vessels involved in the pathological process, and quantitatively assessing the changes detected.

1. Yakovlev S.В., Bocharov A.V., Bukharin E.Yu, Arustamian S.R., Arkhangelskaya Ya.N. Direct carotid-cavernous fistulas: clinical presentation, angioarchitectonics and endovascular management. Burdenko s Journal of Neurosurgery. 2008; 4: 3–11 (In Russ.).

2. Henderson AD, Miller NR. Carotid-cavernous fistula: current concepts in aetiology, investigation, and management. Eye. 2018; 32 (2): 164–72. doi: 10.1038/eye.2017.240

3. Arkhangelskaya Ya.N., Yakovlev S.В. Ophthalmological symptoms of arteriovenous fistulas in the cavernous sinus. In: Serova N.K., ed. Clinical neuro-ophthalmology, neurosurgical aspects. Tver; 2011; 238–45 (In Russ.).

4. Yakovlev S.В., Bocharov A.V., Bukharin E.Yu., Arkhangelskaya Ya.N. Endovascular disconnection of a traumatic carotid-cavernous fistula using a stent graft. Case from practice. Vestnik “Jomedicainforms”. 2005; 2: 8–11 (In Russ.).

5. melo J. Carotid-cavernous fistula from the perspective of an ophthalmologist. A Review. Cesk Slov Oftalmol. 2020; 1: 1–8. doi: 10.31348/2020/8

6. Keltner JL, Satterfield D, Dublin AB, Lee BC. Dural and carotid cavernous sinus fistulas: diagnosis, management, and complications. Ophthalmology. 1987; 94: (12): 1585–600. https://doi.org/10.1016/S0161-6420(87)33258-0150

7. McManus N, Offman RP, Provatas TL, Sievertsen EE. An eye with a heartbeat: Carotid cavernous fistula - a case report. J Emerg Med. 2018; 55 (3): 75–6. doi: 10.1016/j.jemermed.2018.05.015

8. D'Angelo L, Francesco Paglia F, Caporlingua A. Atypical manifestation of direct low-flow carotid-cavernous fistula: Case report and review of the literature. World Neurosurg. 2019; 125: 456–60. doi: 10.1016/j.wneu.2019.02.027

9. Tabashnikova T.V., Serova N.K., Yakovlev S.В. Features of differential diagnosis of direct carotid-cavernous anastomosis. Clinical case. Oftal’mologicheskie vedomosti. 2023; 16 (1): 99–106 (In Russ.). https://doi.org/10.17816/OV112530

10. Chechetkin A.O., Karshieva A.R., Sinitsyn I.A., Konovalov R.N., Gorst N.Kh. Early diagnosis of direct carotid-cavernous fistula. Nervous diseases. 2021; 1: 78–81 (In Russ.). doi: 10.24412/226-0757-2021-12311

11. Venturini M, Cristel G, Marzoli SB, et al. Orbital color Doppler ultrasound as noninvasive tool in the diagnosis of anterior-draining carotid-cavernous fistula. Radiol Med. 2016; 121 (4): 301–7. https://doi.org/10.1007/s11547-015-0607-0

12. Katkova E.A., Vazhenin A.V. Ability to diagnose carotid-cavernous anastomosis. RU Patent 2284153C2, 2006 (In Russ.). https://findpatent.ru/patent/228/2284153.html

13. Chechetkin A.O., Karshieva A.R., Sinitsyn I.A., Konovalov R.N., Gorst N.Kh. Doppler ultrasound in carotid-cavernous fistula diagnosis and follow-up: brief literature review and case report. Ultrasound & Functional Diagnostics. 2021; (1): 50–64 (In Russ.). https://doi.org/10.24835/1607-0771-2021-1-50-64

14. Tseng GW, Kuo TY, Yen PS, Tsai ChH, Lu MK. Sonographic clue in nontraumatic carotid cavernous fistula: report of a case and literature review. Acta Neurol Taiwan. 2020 Mar 30; 29 (1): 18–23. PMID: 32285430.

15. Constantin SM, Ionescu M, Antochi F, et al. The utility of Doppler ultrasonography in carotid-cavernous fistulas. In: Proc. of European Society of Radiology. ECR 2018 Feb 28–Mar 04; Vienna, Austria. Poster C-1201: 1–27. doi: 10.1594/ecr2018/с-1201

16. Srinivasan A, Biro NG, Murchison AP, et al. Efficacy of orbital color Doppler imaging and neuroimaging in the diagnosis of carotid cavernous fistulas. Ophthalmic Plast. Reconstr. Surg. 2017; 33 (5): 340–4. https://doi.org/10.1097/IOP.0000000000000781

17. Kiseleva T.N., Zaitsev M.S., Ramazanova K.A., Lugovkina K.V. Possibilities of color Duplex Imaging in the diagnosis of ocular vascular pathology. Russian ophthalmological journal. 2018; 11 (3): 84–94 (In Russ.). doi: 10.21516/2072-0076-2018-11-3-84-94

18. Baranova E.A., Miftakhova D.Z. Ultrasound methods for diagnosing carotid-cavernous anastomosis. Russian journal of cardiology. 2023; 28 (5S): 37–8 (In Russ.).

19. Alexandre AM, Sturiale CL, Bartolo A, et al. Endovascular treatment of cavernous sinus dural arteriovenous fistulas. Institutional series, systematic review and meta-analysis. Clin Neuroradiol. 2022; 32 (3): 761–71. doi: 10.1007/s00062-021-01107-0

20. Wang J, Shen X, Miao N, et al. Interventional treatment of traumatic carotidcavernous fistula: A case report. Medicine (Baltimore). 2022 Dec 30; 101 (52): e32265. doi: 10.1097/MD.0000000000032265

21. Kruzhkova G.V. Ultrasound diagnosis of orbital diseases. In: Neroev V.V., Kiseleva T.N., ed. Ultrasound examinations in ophthalmology. Guide for doctors. Moscow. 2019; 185–221 (In Russ.).

22. Neroev V.V., Kiseleva T.N., eds. Ultrasound examinations in ophthalmology. Guide for doctors. Moscow; 2019 (In Russ.).

23. Holland LJ, Ranzcr KM, Harrison JD, et al. Endovascular treatment of carotidcavernous sinus fistulas: ophthalmic and visual outcomes. Orbit. 2019 Aug; 38 (4): 290–9. doi: 10.1080/01676830.2018.1544261