Communicating carotid-cavernous sinus fistula following minor head trauma

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Title:
Communicating carotid-cavernous sinus fistula following minor head trauma
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International Journal of Emergency Medicine
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English
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Kaplan, Joshua B.
Bodhit, Aakash N.
Falgiani, Michael L.
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Abstract:
Introduction: A case of communicating carotid-cavernous sinus fistula (CCF) after minor closed head injury is presented. Case presentation: A 45-year-old Caucasian male presented to the emergency department of a tertiary care hospital with the chief complaint of blurred vision and facial numbness. The patient had experienced a minor head injury 1 month ago with loss of consciousness. After a 2-week symptom-free period, he developed scalp and facial numbness, along with headache and vision problems. His vital signs were within normal limits, but on examination the patient was noted to have orbital and carotid bruits with several concerning neurological findings. CT and MRI confirmed the suspicion of carotid-cavernous sinus fistula, which was managed by cerebral angiography with coil embolization of this fistula. The patient was symptom free at the 8-month follow-up. Discussion: Carotid-cavernous sinus fistula is a rare condition that is usually caused by blunt or penetrating trauma to the head, but can develop spontaneously in about one fourth of patients with CCF. The connection between the carotid artery and cavernous sinus leads to increased pressure in the cavernous sinus and compression of its contents, and thereby produces the clinical symptoms and signs seen. Diagnosis depends on clinical examination and neuroimaging techniques. The aim of management is to reduce the pressure within the cavernous sinus, which results in gradual resolution of symptoms.

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Abstract
Introduction
A case of communicating carotid-cavernous sinus fistula (CCF) after minor closed head injury is presented.
Case presentation
A 45-year-old Caucasian male presented to the emergency department of a tertiary care hospital with the chief complaint of blurred vision and facial numbness. The patient had experienced a minor head injury 1 month ago with loss of consciousness. After a 2-week symptom-free period, he developed scalp and facial numbness, along with headache and vision problems. His vital signs were within normal limits, but on examination the patient was noted to have orbital and carotid bruits with several concerning neurological findings. CT and MRI confirmed the suspicion of carotid-cavernous sinus fistula, which was managed by cerebral angiography with coil embolization of this fistula. The patient was symptom free at the 8-month follow-up.
Discussion
Carotid-cavernous sinus fistula is a rare condition that is usually caused by blunt or penetrating trauma to the head, but can develop spontaneously in about one fourth of patients with CCF. The connection between the carotid artery and cavernous sinus leads to increased pressure in the cavernous sinus and compression of its contents, and thereby produces the clinical symptoms and signs seen. Diagnosis depends on clinical examination and neuroimaging techniques. The aim of management is to reduce the pressure within the cavernous sinus, which results in gradual resolution of symptoms.
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Kaplan, Joshua B
Bodhit, Aakash N
Falgiani, Michael L
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A3 FalgianiLMichaelmfalgiani@ufl.edu
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ins Department of Emergency Medicine, University of Florida College of Medicine, 1329 SW 16sup th Street, PO Box 100186, Gainesville, FL 32610, USA
source International Journal of Emergency Medicine
issn 1865-1380
pubdate 2012
volume 5
issue 1
fpage 10
url http://www.intjem.com/content/5/1/10
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cpyrt 2012collab Kaplan et al; licensee Springer.note 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.
abs
sec
st
Abstract
Introduction
A case of communicating carotid-cavernous sinus fistula (CCF) after minor closed head injury is presented.
Case presentation
A 45-year-old Caucasian male presented to the emergency department of a tertiary care hospital with the chief complaint of blurred vision and facial numbness. The patient had experienced a minor head injury 1 month ago with loss of consciousness. After a 2-week symptom-free period, he developed scalp and facial numbness, along with headache and vision problems. His vital signs were within normal limits, but on examination the patient was noted to have orbital and carotid bruits with several concerning neurological findings. CT and MRI confirmed the suspicion of carotid-cavernous sinus fistula, which was managed by cerebral angiography with coil embolization of this fistula. The patient was symptom free at the 8-month follow-up.
Discussion
Carotid-cavernous sinus fistula is a rare condition that is usually caused by blunt or penetrating trauma to the head, but can develop spontaneously in about one fourth of patients with CCF. The connection between the carotid artery and cavernous sinus leads to increased pressure in the cavernous sinus and compression of its contents, and thereby produces the clinical symptoms and signs seen. Diagnosis depends on clinical examination and neuroimaging techniques. The aim of management is to reduce the pressure within the cavernous sinus, which results in gradual resolution of symptoms.
bdy
Introduction
A carotid-cavernous sinus fistula (CCF) is a rare condition well known in the neurosurgical field, but not well published in emergency medicine literature. Whether post-traumatic or spontaneous in nature, the symptoms related to CCFs are insidious and potentially severe. From chronic headaches and diplopia, to intracranial hemorrhage abbrgrp
abbr bid B1 1
and permanent vision loss
B2 2
B3 3
, the ability to identify and manage this disease is essential. The clinical presentations of CCFs can be varied as well, mimicking diseases like multiple sclerosis, brain tumors, or stroke, making it imperative that emergency physicians in the right setting include this disease in their differential diagnosis. We report a case of a patient with a communicating CCF that presented to our Emergency Department (ED) 1 month after suffering a closed head injury at a party.
Case presentation
A 45-year-old Caucasian male presented to the emergency department with the chief complaint of "blurred vision and facial numbness." The patient recalled that a month ago he had been drinking with friends when he was either punched or struck in the back of the head by an unknown object. He lost consciousness but did not seek medical attention at the time, stating that he "felt fine." He remained symptom-free for the next 2 weeks, until he developed left scalp and left facial numbness, and noted that he could not clench his jaw tightly on that side.
Over the next week his symptoms had increased to include: right-sided scalp and forehead numbness, right-sided droopy eyelid, light sensitivity, double vision, difficulty walking in a straight line, bilateral pulsating tinnitus, and a throbbing occipital to retro-orbital headache. With increasing difficulty performing his job as an electrician, he presented to the ED seeking medical attention for the first time.
His past medical history was significant for alcoholism and an old frontal bone fracture suffered as a child. He was not on any medications and had no significant family history. Comprehensive review of systems was otherwise noncontributory.
On physical examination, the patient was wearing sunglasses, in no acute distress. Vital signs were unremarkable. He appeared clinically sober. His visual acuity was 20/30 in each eye, and there were bilateral orbital bruits. The patient declined fundoscopic examination because of significant photophobia. The right eye exhibited: ptosis, inability to adduct, limited elevation and depression. He also could not abduct his left eye. He had decreased sensation to soft touch over the entire forehead, nose, and left cheek, but his corneal reflexes were intact. There was no facial asymmetry. The rest of the cranial nerve examination was intact. Motor strength bilaterally did not reveal any focal neurological deficits, and deep tendon reflexes (DTRs) were 2/4 symmetrical in both the upper and lower extremities. The cerebellar examination was unremarkable except for abnormal tandem gait. Other systemic examinations were unremarkable except for bilateral carotid bruits.
The initial workup in the ED included a complete blood count (CBC), basic metabolic panel (BMP), coagulation studies [prothrombin time (PT), partial thromboplastin time (PTT), international normalization ratio (INR)], and a urine toxicology screen. Each of these studies was without abnormality. A computed tomography (CT) scan of the head without contrast was performed, showing a significantly dilated left ophthalmic vein, seen in Figure figr fid F1 1.
fig Figure 1caption CT of the head without contrasttext
b CT of the head without contrast. Left ophthalmic vein is dilated.
graphic file 1865-1380-5-10-1
Subsequent brain magnetic resonance imaging (MRI) confirmed the suspicion of a carotid artery-cavernous sinus fistula (Figure F2 2). Neurosurgery was consulted. The following day, cerebral angiography with coil embolization of the carotid fistula was performed without complication (Figure F3 3). The patient was discharged the next day. An 8-month follow-up in the neurosurgery clinic revealed complete resolution of his symptoms.
Figure 2MRI of the brain with contrast
MRI of the brain with contrast. Increased flow in the left cavernous sinus and engorgement of the left ophthalmic vein.
1865-1380-5-10-2
Figure 3Cerebral angiography images
Cerebral angiography images. (it Left) Angio-catheterization of the left internal carotid artery (ICA) showing a CCF (arrow). (Right) Post-coil embolization (arrow) of the left CCF.
1865-1380-5-10-3
Discussion
We report a rare condition encountered in the emergency department of a post-traumatic carotid-cavernous fistula. CCFs are formed when there is leakage of arterial flow from the carotid artery into the venous system of the cavernous sinus. This pathological connection leads to rising pressure within the cavernous sinus and compression of its contents, including cranial nerves (CN) III, IV, V, and VI. Involvement of these nerves results in ophthalmoplegia, facial sensory deficits, ptosis, and photophobia. Mounting venous hypertension causes engorgement of the ophthalmic vessels leading to the classic triad of CCFs: orbital bruit, chemosis, and pulsating exophthalmos
B4 4
B5 5
B6 6
B7 7
. Pressure can also be transmitted to the contralateral cavernous sinus via the presence of intercavernous bridging vessels
B8 8
, resulting in bilateral CN deficits and ocular findings, as is seen in this case report.
The vast majority of CCFs follow blunt or penetrating trauma to the head
7
B9 9
B10 10
, with only one quarter occurring spontaneously (often from ruptured aneurysms)
B11 11
. Most cases described in the literature are secondary to closed head injuries related to motor vehicle accidents
7
B12 12
, but as seen in this case, any type of closed head injury can result in a CCF. Symptom onset is typically delayed until venous hypertension reaches a critical level, often days to weeks following the initial insult.
CCFs can be categorized using the Barrow Classification System. Type A fistulas involve a direct communication between the intercavernous portion of the internal carotid artery (ICA) and the cavernous sinus, whereas types B, C, and D are indirect communications between either dural branches of the ICA or external carotid artery (ECA) and the cavernous sinus
7
B13 13
. Type A CCFs are common in young males, as this demographic has a higher incidence of closed head injuries, whereas indirect CCFs occur more often in the elderly
13
.
It is important to distinguish between direct (type A) and indirect (types B-D) fistulas because of the prognostic implications. Direct CCFs are typically high flow and result in significant venous hypertension, while indirect fistulas tend to be low flow
7
B14 14
. These low-flow lesions generally have fewer and less severe symptoms
7
, they improve with time, and often can be medically managed
1
B15 15
. In contrast, it is recommended that all high-flow lesions receive surgical treatment as these can progress to intracranial hemorrhage
1
, vision loss
2
3
, and even life-threatening epistaxis
B16 16
.
The diagnosis of CCFs is based on clinical presentation as well as neuroimaging. A CT scan of the head without contrast may show proptosis, engorgement, and tortuosity of the superior ophthalmic vein, and enlargement of the affected cavernous sinus. MRI images will typically show similar but more pronounced findings compared to CT, and are particularly useful in classifying CCFs
7
13
. If a direct, high-flow CCF is identified, the treatment of choice is endovascular embolization
13
14
. Once the lesion has been embolized, pressure within the cavernous sinus will normalize and symptoms will begin to resolve.
Abbreviations
CCF: Carotid-cavernous sinus fistula; ED: emergency department; DTR: deep tendon reflexes; CBC: complete blood count; BMP: basic metabolic panel; PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized ratio; CT: computed tomography; MRI: magnetic resonance imaging; CN: cranial nerves; ICA: internal carotid artery; ECA: external carotid artery.
Consent
The patient has given consent to present the case and for the use of images of diagnostic procedures.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
JBK and MLF did the clinical examination and clinically managed the patient. JBK drafted the case report manuscript. ANB edited and formatted the manuscript and drafted the abstract for the case report, and prepared the final draft for submission. All authors read and approved the final manuscript.
Authors' information
JBK is the Chief Resident Physician in the Department of Emergency Medicine, University of Florida College of Medicine at Gainesville, FL. ANB is the Research Fellow/Coordinator in the Department of Emergency Medicine, University of Florida. MLF is the Clinical Assistant Professor at the Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida.
bm
refgrp Dural fistulas involving the cavernous sinus: results of treatment in 30 patientsHalbachVVHigashidaRTHieshimaGBetal Radiology1987163437lpage 442link fulltext 3562823Spontaneous carotid-cavernous fistulas: clinical, radiological, and therapeutic considerations: experience with 20 casesVinuelaFFoxAJDebrunGMJ Neurosurg19846097698410.3171/jns.1984.60.5.09766716167Carotid cavernous fistulae: indications for urgent treatmentHalbachVVHieshimaGBHigashidaRTAm J Roentgenol1987149587593Management of 100 consecutive direct carotid-cavernous fistulas: results of treatment with detachable balloonsLewisAITomsickTATewJMsuf JrNeurosurgery19953623924510.1227/00006123-199502000-000017731502Long-term results in direct carotid-cavernous fistulas after treatment with detachable balloonsLewisAITomsickTATewJMJrLawlessMAJ Neurosurgery19968440040410.3171/jns.1996.84.3.0400Treatment of 54 traumatic carotid-cavernous fistulasDeBrunGLacourPVinuelaFJ Neurosurg19815567869210.3171/jns.1981.55.5.06786458669Carotid cavernous fistula: ophthalmological implicationsChaudryAIMiddle East Afr J Ophthalmology2009162576310.4103/0974-9233.53862Intercavernous venous communications in the human skull baseAquiniMSkull Base Surgery19944314515010.1055/s-2008-1058966pmcid 166180217171164Carotid-cavernous fistula syndromeAbrahamsonIAJrBellLBJrAm J Ophthalmol19553952152614361579Dural and carotid cavernous sinus fistulas: Diagnosis, management, and complicationsKeltnerJLSatterfieldDDublinABOphthalmology198794158516003323984Classification and treatment of spontaneous carotid cavernous sinus fistulasBarrowDLSpectorRHBraunIFJ Neurosurg19856224825610.3171/jns.1985.62.2.02483968564Intracranial arteriovenous aneurism or pulsating exophthalmosLockeCEAnn Surg192480124139967217865057Treatment of carotid cavernous fistulasGemmeteJChaudharyNPandeyACurrent Treatment Options in Neurology201012435310.1007/s11940-009-0051-320842489Traumatic carotid cavernous fistulaCorradinoGGelladFESalcmanMSouth Med J19888166066310.1097/00007611-198805000-000303368818Closure of carotid cavernous sinus fistulae by external compression of the carotid artery and jugular veinHigashidaRTHieshimaGBHalbachVVActa Radiol Suppl19863695805832980563An uncommon cause of epistaxis: carotid cavernous fistulaJiamsripongPMookadamMMookadamFEmerg Med J200724e2810.1136/emj.2006.045195265851217452688



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CASEREPORT OpenAccessCommunicatingcarotid-cavernoussinusfistula followingminorheadtraumaJoshuaBKaplan,AakashNBodhit*andMichaelLFalgianiAbstractIntroduction: Acaseofcommunicatingcarotid-cavernoussinusfistula(CCF)afterminorclosedheadinjuryis presented. Casepresentation: A45-year-oldCaucasianmalepresentedtotheemergencydepartmentofatertiarycare hospitalwiththechiefcomplaintofblurredvisionandfacialnumbness.Thepatienthadexperiencedaminorhead injury1monthagowithlossofconsciousness.Aftera2-weeksymptom-freeperiod,hedevelopedscalpandfacial numbness,alongwithheadacheandvisionproblems.Hisvitalsignswerewithinnormallimits,butonexamination thepatientwasnotedtohaveorbitalandcarotidbruitswithseveralconcerningneurologicalfindings.CTandMRI confirmedthesuspicionofcarotid-cavernoussinusfistula,whichwasmanagedbycerebralangiographywithcoil embolizationofthisfistula.Thepatientwassymptomfreeatthe8-monthfollow-up. Discussion: Carotid-cavernoussinusfistulaisarareconditionthatisusuallycausedbybluntorpenetratingtrauma tothehead,butcandevelopspontaneouslyinaboutonefourthofpatientswithCCF.Theconnectionbetween thecarotidarteryandcavernoussinusleadstoincreasedpressureinthecavernoussinusandcompressionofits contents,andtherebyproducestheclinicalsymptomsandsignsseen.Diagnosisdependsonclinicalexamination andneuroimagingtechniques.Theaimofmanagementistoreducethepressurewithinthecavernoussinus, whichresultsingradualresolutionofsymptoms.IntroductionAcarotid-cavernoussinusfistula(CCF)isarareconditionwellknownintheneurosurgicalfield,butnotwell publishedinemergencymedicineliterature.Whether post-traumaticorspontaneousinnature,thesymptoms relatedtoCCFsareinsidiousandpotentiallysevere. Fromchronicheadachesanddiplopia,tointracranial hemorrhage[1]andpermanentvisionloss[2,3],the abilitytoidentifyandmanagethisdiseaseisessential. TheclinicalpresentationsofCCFscanbevariedaswell, mimickingdiseaseslikemultiplesclerosis,braintumors, orstroke,makingitimperat ivethatemergencyphysiciansintherightsettingincludethisdiseaseintheirdifferentialdiagnosis.Wereportacaseofapatientwitha communicatingCCFthatpresentedtoourEmergency Department(ED)1monthaftersufferingaclosedhead injuryataparty.CasepresentationA45-year-oldCaucasianmalepresentedtotheemergencydepartmentwiththechiefcomplaintof blurred visionandfacialnumbness. Thepatientrecalledthata monthagohehadbeendrinkingwithfriendswhenhe waseitherpunchedorstruckinthebackoftheheadby anunknownobject.Helostconsciousnessbutdidnot seekmedicalattentionatthetime,statingthathe felt fine. Heremainedsymptom-freeforthenext2weeks, untilhedevelopedleftscalpandleftfacialnumbness, andnotedthathecouldnotclenchhisjawtightlyon thatside. Overthenextweekhissymptomshadincreasedto include:right-sidedscalpandforeheadnumbness,rightsideddroopyeyelid,lightsensitivity,doublevision,difficultywalkinginastraightline,bilateralpulsatingtinnitus,andathrobbingoccipitaltoretro-orbitalheadache. Withincreasingdifficultyperforminghisjobasanelectrician,hepresentedtotheEDseekingmedicalattentionforthefirsttime. *Correspondence:aakashnb@ufl.edu DepartmentofEmergencyMedicine,UniversityofFloridaCollegeof Medicine,1329SW16thStreet,POBox100186,Gainesville,FL32610,USAKaplan etal InternationalJournalofEmergencyMedicine 2012, 5 :10 http://www.intjem.com/content/5/1/10 2012Kaplanetal;licenseeSpringer.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttribution License(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium, providedtheoriginalworkisproperlycited.

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Hispastmedicalhistorywassignificantforalcoholism andanoldfrontalbonefracturesufferedasachild.He wasnotonanymedicationsandhadnosignificant familyhistory.Comprehens ivereviewofsystemswas otherwisenoncontributory. Onphysicalexamination,thepatientwaswearingsunglasses,innoacutedistress.Vitalsignswereunremarkable.Heappearedclinicallysober.Hisvisualacuitywas 20/30ineacheye,andtherewerebilateralorbitalbruits. Thepatientdeclinedfundoscopicexaminationbecause ofsignificantphotophobia.Therighteyeexhibited:ptosis,inabilitytoadduct,limitedelevationanddepression. Healsocouldnotabducthislefteye.Hehaddecreased sensationtosofttouchovertheentireforehead,nose, andleftcheek,buthiscornealreflexeswereintact. Therewasnofacialasymmetry.Therestofthecranial nerveexaminationwasintact.Motorstrengthbilaterally didnotrevealanyfocalneurologicaldeficits,anddeep tendonreflexes(DTRs)were2/4symmetricalinboth theupperandlowerextremities.Thecerebellar examinationwasunremarkableexceptforabnormaltandemgait.Othersystemicexaminationswereunremarkableexceptforbilateralcarotidbruits. TheinitialworkupintheEDincludedacomplete bloodcount(CBC),basicmetabolicpanel(BMP),coagulationstudies[prothrombintime(PT),partialthromboplastintime(PTT),internationalnormalizationratio (INR)],andaurinetoxicologyscreen.Eachofthesestudieswaswithoutabnormality.Acomputedtomography (CT)scanoftheheadwithoutcontrastwasperformed, showingasignificantlydilatedleftophthalmicvein,seen inFigure1. Subsequentbrainmagneticresonanceimaging(MRI) confirmedthesuspicionofacarotidartery-cavernous sinusfistula(Figure2).Ne urosurgerywasconsulted. Thefollowingday,cerebralangiographywithcoilembolizationofthecarotidfistulawasperformedwithout complication(Figure3).Thepatientwasdischargedthe nextday.An8-monthfollow-upintheneurosurgery clinicrevealedcompleteresolutionofhissymptoms. Figure1 CToftheheadwithoutcontrast .Leftophthalmicveinisdilated. Kaplan etal InternationalJournalofEmergencyMedicine 2012, 5 :10 http://www.intjem.com/content/5/1/10 Page2of5

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DiscussionWereportarareconditionencounteredintheemergency departmentofapost-traumaticcarotid-cavernousfistula. CCFsareformedwhenthereisleakageofarterialflow fromthecarotidarteryintothevenoussystemofthe cavernoussinus.Thispathol ogicalconnectionleadsto Figure2 MRIofthebrainwithcontrast .Increasedflowintheleftcavernoussinusandengorgementoftheleftophthalmicvein. Figure3 Cerebralangiographyimages .( Left )Angio-catheterizationoftheleftinternalcarotidartery( ICA )showingaCCF( arrow ).( Right )Postcoilembolization( arrow )oftheleftCCF. Kaplan etal InternationalJournalofEmergencyMedicine 2012, 5 :10 http://www.intjem.com/content/5/1/10 Page3of5

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risingpressurewithinthecavernoussinusandcompressionofitscontents,includingcranialnerves(CN)III,IV, V,andVI.Involvementofthesenervesresultsinophthalmoplegia,facialsensorydeficits,ptosis,andphotophobia. Mountingvenoushypertensioncausesengorgementofthe ophthalmicvesselsleadingtotheclassictriadofCCFs: orbitalbruit,chemosis,andpulsatingexophthalmos[4-7]. Pressurecanalsobetransmittedtothecontralateralcavernoussinusviathepresenceofintercavernousbridgingvessels[8],resultinginbilateralCNdeficitsandocular findings,asisseeninthiscasereport. ThevastmajorityofCCFsfollowbluntorpenetrating traumatothehead[7,9,10],withonlyonequarter occurringspontaneously(oftenfromrupturedaneurysms)[11].Mostcasesdescribedintheliteratureare secondarytoclosedheadinjuriesrelatedtomotorvehicleaccidents[7,12],butasseeninthiscase,anytypeof closedheadinjurycanresultinaCCF.Symptomonset istypicallydelayeduntilvenoushypertensionreachesa criticallevel,oftendaystoweeksfollowingtheinitial insult. CCFscanbecategorizedusingtheBarrowClassificationSystem.TypeAfistul asinvolveadirectcommunicationbetweentheintercavernousportionofthe internalcarotidartery(ICA)andthecavernoussinus, whereastypesB,C,andDareindirectcommunications betweeneitherduralbranchesoftheICAorexternal carotidartery(ECA)andthecavernoussinus[7,13]. TypeACCFsarecommoninyoungmales,asthis demographichasahigherincidenceofclosedheadinjuries,whereasindirectCCFsoccurmoreofteninthe elderly[13]. Itisimportanttodistinguishbetweendirect(typeA) andindirect(typesB-D)fistulasbecauseoftheprognosticimplications.DirectCCFsaretypicallyhighflowand resultinsignificantvenoushypertension,whileindirect fistulastendtobelowflow[7,14].Theselow-flow lesionsgenerallyhavefewerandlessseveresymptoms [7],theyimprovewithtime,andoftencanbemedically managed[1,15].Incontrast,itisrecommendedthatall high-flowlesionsreceivesurgicaltreatmentasthesecan progresstointracranialhemorrhage[1],visionloss[2,3], andevenlife-threateningepistaxis[16]. ThediagnosisofCCFsisbasedonclinicalpresentationaswellasneuroimaging.ACTscanofthehead withoutcontrastmayshowproptosis,engorgement,and tortuosityofthesuperiorophthalmicvein,andenlargementoftheaffectedcavernoussinus.MRIimageswill typicallyshowsimilarbutmorepronouncedfindings comparedtoCT,andareparticularlyusefulinclassifyingCCFs[7,13].Ifadirect,high-flowCCFisidentified, thetreatmentofchoiceisendovascularembolization [13,14].Oncethelesionhasbeenembolized,pressure withinthecavernoussinuswillnormalizeandsymptoms willbegintoresolve.ConsentThepatienthasgivenconsenttopresentthecaseand fortheuseofimagesofdiagnosticprocedures.Abbreviations CCF:Carotid-cavernoussinusfistula;ED:emergencydepartment;DTR:deep tendonreflexes;CBC:completebloodcount;BMP:basicmetabolicpanel;PT: prothrombintime;PTT:partialthromboplastintime;INR:international normalizedratio;CT:computedtomography;MRI:magneticresonance imaging;CN:cranialnerves;ICA:internalcarotidartery;ECA:externalcarotid artery. Authors contributions JBKandMLFdidtheclinicalexaminationandclinicallymanagedthepatient. JBKdraftedthecasereportmanuscript.ANBeditedandformattedthe manuscriptanddraftedtheabstractforthecasereport,andpreparedthe finaldraftforsubmission.Allauthorsreadandapprovedthefinal manuscript. Authors information JBKistheChiefResidentPhysicianintheDepartmentofEmergency Medicine,UniversityofFloridaCollegeofMedicineatGainesville,FL.ANBis theResearchFellow/CoordinatorintheDepartmentofEmergencyMedicine, UniversityofFlorida.MLFistheClinicalAssistantProfessoratthe DepartmentofEmergencyMedicine,UniversityofFloridaCollegeof Medicine,Gainesville,Florida. Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests. Received:22July2011Accepted:13February2012 Published:13February2012 References1.HalbachVV,HigashidaRT,HieshimaGB, etal : Duralfistulasinvolvingthe cavernoussinus:resultsoftreatmentin30patients. Radiology 1987, 163 :437-442. 2.VinuelaF,FoxAJ,DebrunGM, etal : Spontaneouscarotid-cavernous fistulas:clinical,radiological,andtherapeuticconsiderations:experience with20cases. JNeurosurg 1984, 60 :976-984. 3.HalbachVV,HieshimaGB,HigashidaRT, etal : Carotidcavernousfistulae: indicationsforurgenttreatment. AmJRoentgenol 1987, 149 :587-593. 4.LewisAI,TomsickTA,TewJMJr: Managementof100consecutivedirect carotid-cavernousfistulas:resultsoftreatmentwithdetachableballoons. Neurosurgery 1995, 36 :239-245. 5.LewisAI,TomsickTA,TewJMJr,LawlessMA: Long-termresultsindirect carotid-cavernousfistulasaftertreatmentwithdetachableballoons. J Neurosurgery 1996, 84 :400-404. 6.DeBrunG,LacourP,VinuelaF, etal : Treatmentof54traumaticcarotidcavernousfistulas. JNeurosurg 1981, 55 :678-692. 7.ChaudryAI: Carotidcavernousfistula:ophthalmologicalimplications. MiddleEastAfrJOphthalmology 2009, 16(2) :57-63. 8.AquiniM, etal : Intercavernousvenouscommunicationsinthehuman skullbase. SkullBaseSurgery 1994, 4(3) :145-150. 9.AbrahamsonIAJr,BellLBJr: Carotid-cavernousfistulasyndrome. AmJ Ophthalmol 1955, 39 :521-526. 10.KeltnerJL,SatterfieldD,DublinAB, etal : Duralandcarotidcavernous sinusfistulas:Diagnosis,management,andcomplications. Ophthalmology 1987, 94 :1585-1600. 11.BarrowDL,SpectorRH,BraunIF: Classificationandtreatmentof spontaneouscarotidcavernoussinusfistulas. JNeurosurg 1985, 62 :248-256. 12.LockeCE: Intracranialarteriovenousaneurismorpulsating exophthalmos. AnnSurg 1924, 80 :1-24.Kaplan etal InternationalJournalofEmergencyMedicine 2012, 5 :10 http://www.intjem.com/content/5/1/10 Page4of5

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13.GemmeteJ,ChaudharyN,PandeyA, etal : Treatmentofcarotidcavernous fistulas. CurrentTreatmentOptionsinNeurology 2010, 12 :43-53. 14.CorradinoG,GelladFE,SalcmanM: Traumaticcarotidcavernousfistula. SouthMedJ 1988, 81 :660-663. 15.HigashidaRT,HieshimaGB,HalbachVV, etal : Closureofcarotidcavernous sinusfistulaebyexternalcompressionofthecarotidarteryandjugular vein. ActaRadiolSuppl 1986, 369 :580-583. 16.JiamsripongP,MookadamM,MookadamF: Anuncommoncauseof epistaxis:carotidcavernousfistula. EmergMedJ 2007, 24 :e28.doi:10.1186/1865-1380-5-10 Citethisarticleas: Kaplan etal .: Communicatingcarotid-cavernous sinusfistulafollowingminorheadtrauma. InternationalJournalof EmergencyMedicine 2012 5 :10. Submit your manuscript to a journal and bene t from:7 Convenient online submission 7 Rigorous peer review 7 Immediate publication on acceptance 7 Open access: articles freely available online 7 High visibility within the eld 7 Retaining the copyright to your article Submit your next manuscript at 7 springeropen.com Kaplan etal InternationalJournalofEmergencyMedicine 2012, 5 :10 http://www.intjem.com/content/5/1/10 Page5of5