The

n e w e ng l a n d j o u r na l

of

m e dic i n e

images in clinical medicine

Lindsey R. Baden, M.D., Editor

Carotid Cavernous Fistula

A

B
Cavernous sinus

Cavernous part
of internal
carotid artery
Internal
carotid artery
Fistula

Superior ophthalmic vein

Coils

Cavernous internal
carotid artery

Cavernous sinus

Sudhir Venkataramaiah, M.B.,

B.S., M.D.
Kamath Sriganesh, M.B., B.S.,
M.D., D.M.
National Institute of Mental Health
and Neurosciences
Bangalore, India
vsudhir77@gmail.com

26-year-old man with a history of blunt trauma to the head

2 months earlier presented with rapidly progressive swelling, pain, and diminishing vision in the left eye. The physical examination of the left eye
revealed chemosis, pulsating proptosis, and an ulcerated cornea (Panel A). A bruit
could be heard with a stethoscope placed on the left temple. Selective angiography
of the left carotid artery showed a fistulous communication between the internal
carotid artery and the cavernous sinus (Panel B, lateral projection) and early filling
of the superior ophthalmic vein (Panel C, lateral projection). Under general anesthesia, the patient underwent endovascular coiling of the fistula (Panel D). At 6 months
after the coiling procedure, there was a 95% reduction in the patients proptosis.
Carotid cavernous fistula is an abnormal arteriovenous communication between
the carotid artery or its branches and the cavernous sinus. It can result from blunt
trauma to the skull. As arterial blood enters the cavernous sinus under high pressure, normal venous return is impeded, leading to engorgement of the draining
veins. The mainstay of therapy is endovascular occlusion of the affected cavernous
sinus with coils, glue, or balloons.

DOI: 10.1056/NEJMicm1311966
Copyright 2014 Massachusetts Medical Society.

1832

n engl j med 371;19

nejm.org

november 6, 2014

The New England Journal of Medicine

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Copyright 2014 Massachusetts Medical Society. All rights reserved.