Endoscopic Endonasal Orbital Decompression for Carotid Cavernous Fistula

A carotid cavernous fistula is a pathological connection between the internal carotid artery and the cavernous sinus venous plexus. This is a rare condition that can have severe consequences including: extraocular motility disturbances, visual field and acuity loss, and death. Management options reported in the literature include endovascular embolization and radiosurgery. We report a rare case of acute abducens nerve palsy from carotid cavernous fistula treated with surgical decompression. A 43-year-old woman presented to the hospital with 1-week history of headache and vertigo and diplopia for 2 days. Initial ophthalmologic exam demonstrated complete left lateral gaze restriction with no loss of central, color, or peripheral vision. A screening intracranial CT angiography demonstrated a 4-mm focal saccular aneurysm at the origin of the left ophthalmic artery within the left optic strut. However, cerebral angiogram demonstrated a low-flow carotid cavernous fistula from the meningohypophyseal branch of the internal carotid artery. Our oculoplastic surgery team attempted maximum medical treatment with 48 hours of high-dose steroid therapy. Given her lack of response, she underwent surgical decompression of the bilateral sphenoid sinus, medial orbital wall, cavernous sinus, orbital apex, and optic canal via endoscopic endonasal approach. The patient showed immediate improvement in diplopia and had reduced gaze restriction. One-month postoperative visit demonstrated complete resolution of headache, −0.5 left lateral gaze ocular motility restriction. At 2-month follow-up, the patient had resolution of diplopia in primary gaze. To our knowledge, this is the first report of endoscopic endonasal decompression of the orbital apex for an indirect carotid cavernous fistula.

Publication History

Article published online:
12 February 2021