Alteration of choroidal thickness in a case of carotid cavernous fistula: a case report and a review of the literature
© Shinohara et al.; licensee BioMed Central Ltd. 2013
Received: 28 April 2013
Accepted: 29 November 2013
Published: 5 December 2013
To measure the alterations of the choroidal thickness in Carotid cavernous fistula (CCF) using enhanced depth imaging optical coherence tomography (EDI-OCT).
A 64-year-old woman was referred to us for redness, exophthalmos and visual disturbance in her right eye. She was diagnosed with CCF by magnetic resonance imaging (MRI) and magnetic resonance angiography.
Observations; Embolization resulted in improvement of ocular symptoms, and there was a reduction of the subfoveal choroidal thickness in the right eye from 351 μm preoperatively to 142 μm postoperatively in EDI-OCT.
EDI-OCT demonstrated that the choroidal thickness increases occurred due to congestion in a CCF case.
Carotid cavernous fistula (CCF) is an abnormal connection between the carotid arterial system and the cavernous sinus . These cases typically have a low flow and present with oculo-orbital venous congestive features such as exophthalmos, chemosis, and sometimes oculomotor or abducens cranial nerve palsy . Angiography is an essential tool for making a direct diagnosis and therapeutic determination of CCF. Arteriovenous fistula occurs after trauma or develops spontaneously after rupture of a cavernous carotid aneurysm or a preexisting weakness of the arterial wall.
Barrow et al. have classified CCF into four types based on the arterial system involved. Type A, or direct, CCF is high-flow shunts between the main trunk of internal carotid artery and the cavernous sinus. The other three types are indirect, or dural, CCFs, which arise from the dural branches of internal, external carotid system or both (type B, C, and D) . Even though some dural fistulas close spontaneously, therapeutic intervention of dural fistulas should be reserved for the patients with visual deterioration. Intravascular coil occlusion of the superior and inferior ophthalmic veins and cavernous sinus of the symptomatic eye is a highly efficient and safe treatment for these conditions [4, 5]. Previous studies have demonstrated that one of the typical symptoms of CCF is congestion of the ocular veins, such as the conjunctival, episcleral and retinal veins. However, dural arteriovenous fistula sometimes exhibits a milder shunt flow and symptoms [2, 6–8]. In the current report, we used enhanced depth imaging optical coherence tomography (EDI-OCT) (Spectralis; Heidelberg Engineering, Heidelberg, Germany) before and after an endovascular embolization and documented the alterations of the choroidal thickness in a CCF patient.
The newly developed EDI-OCT technique has enabled visualization of the choroid. Moreover, use of this method has made it possible to measure the choroidal thickness without having to perform an invasive examination [9, 10]. EDI-OCT examinations of eyes with central serous choroidopathy have reported finding a significantly thicker choroidal thickness as compared to that observed in normal eyes [11, 12]. Furthermore, EDI-OCT has shown that the choroid is thinner in cases of myopic shift or axial length elongation . Due to the recent progress that has been made when using new imaging techniques, such as EDI-OCT and swept source OCT, our current study decided to focus on the choroid. Since indocyanine green angiography has been shown to be able to detect CCF , we were able to diagnose CCF in our current case. Upon further examination with EDI-OCT and cerebral angiography, we could subsequently prove that the choroidal thickness increases occurred due to congestion. Since we also determined that the postoperative choroidal thickness was significantly thinner than normal, this suggests the change may be due to the choroidal atrophy that was caused by the long-standing congestion. Although the preoperative blood flow was shown to be slow due to congestion, LSFG which commonly express choroidal blood flow volume  demonstrated there was drastic increase in the postoperative blood flow volume nevertheless the volume was not recovered as high as left eye because longstanding congestion may lead choroidal atrophic change. To the best of our knowledge, this is the first report that has proved the relationship between an increased choroidal thickness by EDI-OCT and choroidal congestion by cerebral angiography in CS-DAVF.
- Pillai GS, Ghose S, Singh N, Garodia VK, Puthassery R, Manjunatha NP: Central retinal artery occlusion in dural carotid cavernous fistula. Retina. 2002, 22: 493-494. 10.1097/00006982-200208000-00015.View ArticlePubMedGoogle Scholar
- Kirsch M, Henkes H, Liebig T, Weber W, Esser J, Golik S, Kuhne D: Endovascular management of dural carotid-cavernous sinus fistulas in 141 patients. Neuroradiology. 2006, 48: 486-490. 10.1007/s00234-006-0089-9.View ArticlePubMedGoogle Scholar
- Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT: Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg. 1985, 62: 248-256. 10.3171/jns.1985.62.2.0248.View ArticlePubMedGoogle Scholar
- Men S, Ozturk H, Hekimoglu B, Sekerci Z: Traumatic carotid-cavernous fistula treated by combined transarterial and transvenous coil embolization and associated cavernous internal carotid artery dissection treated with stent placement. Case report. J Neurosurg. 2003, 99: 584-586. 10.3171/jns.2003.99.3.0584.View ArticlePubMedGoogle Scholar
- Hurst RW, Howard RS, Zager E: Carotid cavernous fistula associated with persistent trigeminal artery: endovascular treatment using coil embolization. Skull base surgery. 1998, 8: 225-228. 10.1055/s-2008-1058188.View ArticlePubMedPubMed CentralGoogle Scholar
- Benndorf G: Dural cavernous sinus fistulas: diagnosis and endovascular therapy. 2010, Berlin: SpringerView ArticleGoogle Scholar
- Pierre Filho Pde T, Medina FM, Rodrigues FK, Carrera CR: Central retinal artery occlusion associated with traumatic carotid cavernous fistula: case report. Arq Bras Oftalmol. 2007, 70: 868-870. 10.1590/S0004-27492007000500026.View ArticlePubMedGoogle Scholar
- Ishijima K, Kashiwagi K, Nakano K, Shibuya T, Tsumura T, Tsukahara S: Ocular manifestations and prognosis of secondary glaucoma in patients with carotid-cavernous fistula. Jpn J Ophthalmol. 2003, 47: 603-608. 10.1016/j.jjo.2003.08.002.View ArticlePubMedGoogle Scholar
- Spaide RF, Koizumi H, Pozzoni MC: Enhanced depth imaging spectral-domain optical coherence tomography. Am J Ophthalmol. 2008, 146: 496-500. 10.1016/j.ajo.2008.05.032.View ArticlePubMedGoogle Scholar
- Ikuno Y, Maruko I, Yasuno Y, Miura M, Sekiryu T, Nishida K, Iida T: Reproducibility of retinal and choroidal thickness measurements in enhanced depth imaging and high-penetration optical coherence tomography. Invest Ophthalmol Vis Sci. 2009, 52: 5536-5540.View ArticleGoogle Scholar
- Maruko I, Iida T, Sugano Y, Ojima A, Ogasawara M, Spaide RF: Subfoveal choroidal thickness after treatment of central serous chorioretinopathy. Ophthalmology. 2010, 117: 1792-1799. 10.1016/j.ophtha.2010.01.023.View ArticlePubMedGoogle Scholar
- Imamura Y, Fujiwara T, Margolis R, Spaide RF: Enhanced depth imaging optical coherence tomography of the choroid in central serous chorioretinopathy. Retina. 2009, 29: 1469-1473. 10.1097/IAE.0b013e3181be0a83.View ArticlePubMedGoogle Scholar
- Fujiwara T, Imamura Y, Margolis R, Slakter JS, Spaide RF: Enhanced depth imaging optical coherence tomography of the choroid in highly myopic eyes. Am J Ophthalmol. 2009, 148: 445-450. 10.1016/j.ajo.2009.04.029.View ArticlePubMedGoogle Scholar
- Sutoh N, Muraoka K, Takahashi K, Ikeda F, Shimizu K: Remodelling of choroidal circulation in carotid cavernous sinus fistula. Retina. 1996, 16: 497-504.View ArticlePubMedGoogle Scholar
- Watanabe G, Fujii H, Kishi S: Imaging of choroidal hemodynamics in eyes with polypoidal choroidal vasculopathy using laser speckle phenomenon. Jpn J Ophthalmol. 2008, 52: 175-181. 10.1007/s10384-007-0521-7.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2415/13/75/prepub
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.