traumatic internal carotid cavernous fistula
Introduction
Introduction to traumatic carotid cavernous fistula Traumatic carotid cavernous sinus fistula refers to the internal carotid artery or its branch located in the cavernous sinus. It is caused by traumatic rupture and direct communication with veins, forming venous and venous fistulas. The cause is often caused by skull base fracture. The incidence rate is about 2.5%. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: skull base fracture benign intracranial hypertension cerebral palsy
Cause
Traumatic carotid cavernous fistula
(1) Causes of the disease
Skull base fracture can cause damage to the cavernous sinus segment or its branches of the internal carotid artery, or firearm injury, sharp injury directly to the artery, or rupture of the internal carotid artery wall in the sinus segment due to severe turbulent blood flow. Factors can also cause punctiform hemorrhage or localized damage to the arterial wall, and subsequent rupture of the cavernous sinus due to severe fluctuations in blood pressure.
(two) pathogenesis
Because the cavernous sinus segment of the internal carotid artery is firmly fixed by the dura at its entrance and exit, when the fracture line crosses the middle cranial fossa or walks to the saddle, the artery or its branches can be torn, sometimes due to fracture Fragmentation, penetrating injury or direct damage caused by flying objects, damaged arteries or rupture or delayed rupture, so the symptoms of venous sputum appear different after the injury, acute immediately appear, late for several days , a few weeks, often have an asymptomatic intermittent period and then the onset.
Once the internal carotid artery breaks into the cavernous sinus, not only the blood of the damaged artery directly flows into the venous system to form a short circuit, causing all the venous engorgement of the cavernous sinus, and the internal carotid artery belongs to each other due to the stealing of the mouth. The blood flow is reversed, causing related brain ischemia. In severe cases, brain function damage and increased intracranial pressure may occur. Even due to massive shunting of arteriovenous fistula, compensatory heart enlargement may occur, and sometimes hemorrhage through the skull base and into the sphenoid sinus. Can cause a large number of fatal nosebleeds. If the bleeding enters the subarachnoid space, it will lead to acute intracranial hypertension, which will eventually die due to cerebral palsy.
Prevention
Traumatic carotid cavernous fistula prevention
The disease is a traumatic disease, pay attention to safety, drive carefully, keep the home environment bright, walk carefully, watch children and avoid trauma.
Complication
Traumatic carotid cavernous fistula complications Complications, skull base fracture, benign intracranial hypertension, cerebral palsy
Once the internal carotid artery breaks into the cavernous sinus, not only the blood of the damaged artery directly flows into the venous system to form a short circuit, causing all the venous engorgement of the cavernous sinus, and the internal carotid artery belongs to each other due to the stealing of the mouth. The blood is countercurrent, causing related brain ischemia. In severe cases, brain function damage and increased intracranial pressure may occur. Even due to massive shunting of arteriovenous fistula, compensatory heart enlargement may occur, and sometimes hemorrhage through the skull base and into the sphenoid sinus. It can cause a fatal mass of nasal discharge. If the bleeding enters the subarachnoid space, it will lead to acute intracranial hypertension and eventually death due to cerebral palsy.
Symptom
Traumatic carotid cavernous fistula symptoms common symptoms insomnia visual impairment corneal ulcer optic atrophy nosebleed sensory disorder retinal edema coma diplopia eyeball
Patients with coma after injury, the symptoms of cavernous sinus leakage of the internal carotid artery can appear immediately after the injury, or appear several hours, several days or even months after the injury, the clinical manifestations and the size of the arteriovenous fistula formed by internal carotid artery injury related.
Local symptoms
It is caused by the direct injection of internal carotid artery blood flow into the cavernous sinus.
(1) pulsatile ocular protrusion: within 24 hours after injury, there is concomitant ocular ocular edema, valgus, ocular protrusion and pulsation consistent with heart rhythm, frontotemporal scalp vein engorgement.
(2) Tremor and murmur: The continuous murmur that the patient can hear is enhanced with the contraction of the heart, the occlusion of the eyeball is tremor, the eyeball is auscultated, the sputum and the ankle can smell the murmur and the cat tremor The two are consistent with the pulse, and the murmur can significantly insomnia the patient, and the compression of the ipsilateral common carotid artery can weaken or disappear the murmur.
(3) Visual impairment: due to elevated ocular venous pressure, retinal edema, hemorrhage, optic disc edema, or primary optic atrophy due to enlarged cavernous sinus oppression of the optic nerve, resulting in visual impairment.
(4) cavernous sinus and supracondylar fissure syndrome: about 70% of patients with limited eye movement, especially the involvement of the nerves and oculomotor nerves, can cause diplopia, severe membrane inflammation, corneal ulcers, Eyeball compression glaucoma and optic atrophy, even blindness, occasionally patients with trigeminal nerve branch symptoms, such as the frontal frontotemporal, ankle pain or forehead skin sensory disturbance and corneal reflex weakening, in addition, some patients may be due to cavernous sinus Larger, the traffic on both sides is very easy, and there are symptoms and signs of bilateral eyes.
2. Whole brain symptoms
Because of cerebral ischemia, when the internal carotid cavernous sinus fistula, short circuit blood circulation is formed between the artery and the cavernous sinus, affecting the blood flow of the middle cerebral artery and anterior cerebral artery in the distal part of the sputum, and the cerebral insufficiency occurs in the corresponding distribution area. Long-term cerebral ischemia causes functional damage to the brain, and sometimes intracranial pressure may increase.
In addition, if the carotid artery rupture and the sphenoid sinus, it can cause a large number of nosebleeds, usually in the early or after a few days after the injury, if the sinus ostium is larger, the modern compensatory heart enlargement.
Examine
Traumatic carotid cavernous fistula examination
It is often necessary to use the femoral artery cannulation to perform whole-brain selective angiography. In addition to the external carotid artery and the external carotid artery angiography, the contralateral carotid artery is also compressed to temporarily block the blood flow. Internal carotid artery and vertebral artery image, energy in the ipsilateral carotid artery image, only a shadow of contrast agent in the cavernous sinus, the distal cerebral vascular filling is poor, the exact location of the fistula is difficult to determine, using vertebral artery The angiography simultaneously compresses the carotid artery of the affected side, so that the contrast agent is retrogradely discharged through the internal carotid cavernous sinus fistula, which is often clearly visible. At the same time, the internal carotid artery angiography can also understand whether the Willis ring is intact, and the cerebral artery is estimated. The compensation situation can help to determine whether the blood flow of the internal carotid artery can be interrupted. In addition, the selective external carotid artery angiography can show the presence or absence of the branch of the internal carotid artery and the middle meningeal artery of the cavernous sinus, the meningeal artery and the pharynx. The ascending artery is anastomosed to form a blood supply to the external carotid artery.
Diagnosis
Diagnosis and diagnosis of traumatic carotid cavernous fistula
diagnosis
According to the history of craniocerebral trauma and the above-mentioned unique eye signs, the diagnosis can be confirmed. Some patients have higher arterial pressure, and at the same time or later, the contralateral eyeballs protrude. When the side is fixed, attention should be paid to the patients. The type and location of the fistula should be determined at the time of diagnosis. From the point of view of treatment, the purpose and requirements of the diagnosis should also include the location, size, degree of stealing blood, source of blood supply to the mouth, and the base of the brain artery (Willis Circle). The situation and the direction of the venous drainage are convenient for selecting appropriate treatment methods.
Therefore, it is often necessary to use the femoral artery cannula to perform whole brain selective angiography, in addition to the contralateral neck and external carotid artery angiography, but also in the case of oppressing the affected carotid artery and temporarily blocking the blood flow. Imaging of the contralateral internal carotid artery and vertebral artery, usually in the imaging of the internal carotid artery of the affected side, only a shadow of contrast agent in the cavernous sinus is seen, the distal cerebral vascular filling is poor, and the exact location of the fistula is difficult to determine. Vertebral angiography simultaneously compresses the carotid artery of the affected side, so that the contrast agent is retrogradely discharged through the internal carotid cavernous sinus fistula, which is often clearly visible. At the same time, the internal carotid artery angiography can also understand whether the Willis ring is intact. Cerebral arterial compensation can help to determine whether the blood flow of the internal carotid artery can be interrupted. In addition, the selective external carotid artery angiography can show the presence or absence of the branch of the internal carotid artery and the middle meningeal artery of the cavernous sinus, and the meningeal artery. The pharyngeal ascending artery is anastomosed, and the external carotid artery is formed. Parkinson (1967) divided the traumatic carotid cavernous fistula into two categories:
First, it is caused by the rupture of the internal carotid artery of the cavernous sinus segment;
Second, it is caused by the branch fracture of the internal carotid artery of the cavernous sinus segment, and the latter is often difficult to use with simple balloon embolization.
Clinically, it needs to be differentiated from intraorbital meningioma, intraorbital aneurysm and cavernous sinus thrombosis. In addition, pulsatile exophthalmos caused by other vascular malformations in the brain should be excluded. Intracranial vascular murmurs, such as dural arteriovenous fistula , brain arteriovenous fistula.
