J Clin Neurol.  2011 Sep;7(3):164-167. 10.3988/jcn.2011.7.3.164.

Spontaneous Carotid Cavernous Fistula in a Case with Protein S Deficiency that Newly Developed Ophthalmoplegia after Embolization

• Kim CK
• Shin JY
• Chang JY
• Lee SH

• KMID: 2287633
• DOI: http://doi.org/10.3988/jcn.2011.7.3.164

Abstract

BACKGROUND
Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus. The pathogenesis of spontaneous CCF remains unclear, although sinus thrombosis is known to be a predisposing factor for dural arteriovenous fistula. Because spontaneous CCFs are mainly of the dural type, we considered that thrombogenic conditions, such as, protein S deficiency might be associated with CCF.
CASE REPORT
A 42-year-old woman complained of conjunctival injection and retro-orbital pain that first appeared 1-month before visiting our hospital. She had no history of head trauma or intracranial surgery. Exophthalmos and chemosis were observed in her left eye, which also had lower visual acuity and higher intraocular pressure than the right eye. Magnetic resonance images and cerebral angiography revealed a left dural CCF. Her protein S was low, at 41% (normal range: 70-140%), but other hematologic values related to coagulation were normal. Her symptoms were relieved after initial transvenous coil embolization. However, a newly developed sixth-nerve palsy was detected 4 days after initial embolization. Follow-up angiography revealed a minimal shunt, and thus transvenous coil embolization was repeated. Two days later, the ophthalmoplegia started reducing, and 1-month later it had almost disappeared.
CONCLUSIONS
To the best of our knowledge, this is the first report of spontaneous dural CCF in a Korean patient with concurrent protein S deficiency. Interestingly, transient sixth-nerve palsy developed after transvenous coil embolization in this patient. This additional symptom caused by the residual fistula was relieved after additional transarterial embolization.

Keyword

carotid cavernous fistula; protein S deficiency; transvenous embolization; sixth-nerve palsy; complication

MeSH Terms

Adult
Angiography
Carotid Arteries
Cavernous Sinus
Caves
Central Nervous System Vascular Malformations
Cerebral Angiography
Craniocerebral Trauma
Exophthalmos
Eye
Female
Fistula
Follow-Up Studies
Humans
Intraocular Pressure
Magnetic Resonance Spectroscopy
Ophthalmoplegia
Paralysis
Protein S
Protein S Deficiency
Sinus Thrombosis, Intracranial
Visual Acuity
Protein S

Figure

• 

  Fig. 1 Cerebral angiography images show a left CCF fed by the bilateral internal and external carotid arteries. A: Lateral arteriogram of left external carotid artery. B: Lateral arteriogram of left internal carotid artery. C: Anteroposterior arteriogram of right internal carotid artery. D: Magnetic resonance images indicate a prominent superior ophthalmic vein. CCF: carotid cavernous fistula.

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