PMC9610209_01
Imaging exams. (a) Diagnostic brain angiography (left ICA - lateral view) showing a CCF. The arteriovenous shunt in the left CS drains retrogradely into the ipsilateral superior ophthalmic vein (which is enlarged). (b) Postoperative CTA reconstruction shows normal-appearing ICA (black arrow), preserved flow, and excludes arterial lesion or dissection. (c) Preoperative CTA reconstruction shows an important dilation of the superior ophthalmic vein inside the orbit. (d) Postoperative CTA reconstruction demonstrates the absence of contrast in the left superior ophthalmic vein and the absence of flow in the ipsilateral facial vein (which was well visualized in the preoperative imaging exam). We believe that the rapidly progressive worsening of visual function was secondary to angular and facial veins thrombosis after attempted catheterization of the superior ophthalmic vein. (e) Preoperative CTA with extravasation of contrast within the CS in the arterial phase and demonstrating the superior ophthalmic vein dilated and precociously contrasted. (f) Postoperative CTA with contrast exclusively in the cavernous segment of the ICA (no extravasation into the CS) and no contrast in the superior ophthalmic vein. ICA: Internal carotid artery, CS: Cavernous sinus, CTA: Computed tomography angiography, CCF: Carotid cavernous fistula.
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F1
Postoperative CTA showed no surgical complications and no arterial filling of the CS or retrograde venous filling of the superior ophthalmic vein [Figure 1].
(a) Patient on the operating table just before surgery. Amaurosis and paralysis of the cranial nerves responsible for extrinsic ocular movement (III, IV, and VI) of the left eye. Significant chemosis is noted. (b) Patient on the operating table immediately after surgery. Significant decrease in chemosis is observed. (c) At the outpatient consultation, 21 days after surgery, the patient had complete resolution of proptosis and chemosis, decreased of the VI left cranial nerve previous paresis, and unfortunately persistence of ipsilateral blindness.
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F2
At the outpatient consultation, 21 days after surgery, the patient had complete resolution of proptosis and chemosis, decreased of the VI left cranial nerve previous paresis, and persistence of ipsilateral blindness [Figure 2].