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Post-traumatic carotid-cavernous fistula in a pediatric patient: a case-based literature review
Barbara Albuquerque Morais1, Vitor Nagai Yamaki2, Jose Guilherme Mendes Pereira Caldas3
1Department of Neurosurgery, School of Medicine, University of Sao Paulo, Rua Dr Eneas de Carvalho, Street Eneas de Carvalho, 155, Pinheiros, Sao Paulo, SP, Brazil. babyamorais@gmail.com.
Insights
A rare carotid-cavernous fistula (CCF) in a child, resulting from head trauma, was successfully treated with endovascular ballooning. Early diagnosis of CCF in pediatric head trauma is crucial for preventing neurological deficits.
Area of Science:
- Ophthalmology
- Neurology
- Vascular Surgery
Background:
- Carotid-cavernous fistula (CCF) is an abnormal connection between the carotid artery and the cavernous sinus, often resulting from head trauma.
- Traumatic CCFs represent a small percentage of head injuries, particularly in the pediatric population.
- Type A CCF, a direct high-flow shunt, is the most common form, frequently linked to trauma or aneurysm rupture.
Observation:
- An 8-year-old boy presented with penetrating eye trauma; initial CT scans were normal.
- Seven days post-discharge, the patient developed proptosis, chemosis, cranial nerve palsies (III, IV, VI), ptosis, and mydriasis.
- Arteriography confirmed a post-traumatic carotid-cavernous fistula.
Findings:
- Endovascular detachable balloon treatment was effective for the pediatric traumatic CCF.
- Skull base fractures on CT are not reliable indicators for diagnosing CCF in head trauma patients.
- Ocular symptoms following craniofacial trauma warrant suspicion for CCF.
Implications:
- Prompt diagnosis and intervention for CCF can avert permanent neurological damage and improve patient outcomes.
- This case highlights the importance of vigilance for CCF in pediatric patients with head and facial injuries.
- Endovascular techniques offer a viable treatment option for traumatic CCF in children.
Background:
Carotid-cavernous fistula (CCF) is a shunt between the carotid artery and the cavernous sinus. Traumatic CCFs are diagnosed in 0.2% of head traumas being only 4.6% of the pediatric population. Classified by Barrow in 1985, type A CCF is the most frequent, occurring in 75% of cases. Type A is characterized by direct and high-flow CCF that generally can occur as a result of traumatic injury or rupture of an intracavernous aneurysm.
Case Presentation:
The subject was an 8-year-old boy with penetrating trauma to his left eye. During the initial evaluation, a computed tomography (CT) scan was unremarkable, and after relief of symptoms, the patient was discharged. Seven days later, he developed grade I proptosis, conjunctival chemosis, ophthalmoplegia (III, IV, and VI cranial nerve palsies), and left-sided ptosis and mydriasis. Arteriography confirmed a post-traumatic CCF, and the patient was treated with an endovascular detachable balloon.
Conclusion:
CCF should be suspected in craniofacial traumas with ocular symptoms. The presence of a skull base fracture on CT is a poor predictor of CCF associated with head trauma. Early diagnosis and treatment can prevent permanent neurological deficits and unfavorable outcomes.
