02.12.

2016

CavernousSinusSyndromes:Overview,ClinicalPresentation,DiagnosticWorkup

Thissiteisintendedforhealthcareprofessionals

CavernousSinusSyndromes
Updated:Feb14,2014
Author:JorgeCKattah,MDChiefEditor:RobertAEgan,MDmore...

OVERVIEW

Overview
Background
Cavernoussinussyndromeisdefinedbyitsresultantsignsandsymptoms:ophthalmoplegia,
chemosis,proptosis,Hornersyndrome,ortrigeminalsensoryloss.Infectiousornoninfectious
inflammatory,vascular,traumatic,andneoplasticprocessesaretheprincipalcauses.Examplesof
specificentitiesthatmayresultincavernoussinussyndromearemyriadandincludecarotidartery
aneurysms,carotidcavernousfistulas(CCfistulas)(seeimagebelow),tumors,andTolosaHunt
syndrome,tonamethemostfrequentlydiscussed.

Carotidcavernousfistula.

ViewMediaGallery

Pathophysiology
Thecavernoussinusesarepaired,venousstructureslocatedoneithersideofthesellaturcica.
Theyreceivevenoustributariesfromthesuperiorandinferiororbitalveinsanddrainintothe
superiorandinferiorpetrosalsinuses.Thecavernoussinuscontainsthecarotidartery,its
sympatheticplexus,andtheoculomotornerves(third,fourth,andsixthcranialnerves).Inaddition,
theophthalmicbranchandoccasionallythemaxillarybranchofthefifthnervetraversethe
cavernoussinus.Thenervespassthroughthewallofthesinuswhilethecarotidarterypasses
throughthesinusitself.

Cavernoussinustumors
Cavernoussinustumorsarethemostcommoncauseofcavernoussinussyndrome.Tumorsmay
beprimaryormayarisefromeitherlocalspreadorasmetastases.Examplesofprimarytumors
includemeningiomasorneurofibromas.Examplesoflocallyspreadingtumorsarenasopharyngeal
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carcinomaorpituitarytumors.Metastaticlesionsaremostoftenfromthebreast,prostate,orlung.
Radiotherapymayoffertransientrelief,particularlyinnasopharyngealcancer.Lateralextensionof
pituitarytumorsmaybetreatedwithsurgicalresectionanddopamineagonistsinthecaseof
prolactinoma.Totalresectionoftheselesionsischallengingandattemptedonlywhenthe
symptomsaredisabling.[1]

Cavernoussinusaneurysms
Unlikeintracranialaneurysmsinotheranatomiclocations,carotidcavernousaneurysmsdonot
involveamajorriskofsubarachnoidhemorrhage.However,theirrupturecanresultindirectCC
fistulas,whichmayleadtocerebralhemorrhage.Theseaneurysms,whicharemorefrequentinthe
elderlypopulation,presentwithanindolentophthalmoplegia.Althoughsomepatientssufferminor
disabilityanddonotrequiretreatment,endovascularocclusionoftheselesionsisoftensuccessful
andmaybeattemptedinselectedpatients.[2]

Carotidcavernousfistulas
CCfistulasareof2types:directandindirect.Directfistulasoccurifthecarotidarteryand
cavernoussinusareincontinuity.Theymanifestwithabruptonsetofproptosis,chemosis,visual
loss,andophthalmoplegia.Indirectfistulasoccurwithcommunicationbetweenthecavernous
sinusandthebranchesoftheinternalcarotidartery,externalcarotidartery,orboth.Theyhavea
moreinsidiouspresentationthandirectfistulas,oftenwithspontaneousresolution.Traumaor
aneurysmruptureisacommoncauseofcarotidcavernousfistulas.Interventionalradiologistscan
successfullytreatallfistulatypesbyendovascularocclusiontechniques.Occasionally,surgical
treatmentwithcarotidligationisnecessarythissometimesisprecededbyasuperficialtemporal
tomiddlecerebralbypassoperationtoensurecerebralcirculationaftercarotidligation.

Frequency
IntheUS,approximately5%ofophthalmoplegiasaresecondarytoinvolvementofcranialnerves
inthecavernoussinuses.Thisisprobablytrueworldwide.
Cavernoussinusaneurysmsrepresent5%ofallintracranialaneurysms.

Mortality/Morbidity
Seethelistbelow:
Mostofthelesionsaffectingthecavernoussinusesaretreatable.
Metastaticcancerisafrequentcauseofcavernoussinussyndromes,andtheprognosis
dependsonthespecifictumortype.
Cavernoussinussepticthrombophlebitismortalityhasdecreasedfrom100%to20%withthe
implementationofimprovementindiagnosisandtherapeutics.
CavernoussinusaneurysmsandCCfistulascanbetreatedsuccessfullybyendovascular
techniques.
Lateralextensionofpituitarytumors,acommoncauseofthissyndrome,canbetreatedby
surgicalresection,radiationtherapyinselectedpatients,andadopamineagonistinthecase
ofprolactinoma.

ClinicalPresentation
History
Thesignsandsymptomsfrequentlyfoundinpatientswithcavernoussinuslesionsincludevisual
loss,proptosis,ocularandconjunctivalcongestion,elevationofocularpressure,ophthalmoplegia,
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andpain.Variouscombinationsofthesesymptomsmayoccur,whichgenerallyareunilateral,but
maybebilateralwithneoplasticprocesses.Symptomsmaybeacuteorslowlyprogressive.
Primarytumorsarethemostfrequentneoplasmresponsibleforacavernoussinussyndrome.
Cavernoussinustumors
Acuteorslowlyprogressiveophthalmoplegiaisthedominantpresentation,withdiplopia
beingthemostcommonsymptom.
Attimes,painfuldiplopiaispresent.
Usuallythepatienthasaprecedinghistoryofcancer.Occasionally,cavernoussinus
syndromeisthefirstmanifestationofasystemicneoplasm.
Exophthalmoscanbeseen.
Ifthetumorisapituitaryadenoma,endocrinesymptomsandvisualfielddeficitsmaybe
present.
Carotidcavernousaneurysms
Patientsfrequentlyareelderlyandpresentwithsubacuteorchronicophthalmoplegia.
Rarely,theymayhavepainsimilartothatoftrigeminalneuralgia.
Spontaneousruptureofacarotidcavernousaneurysmleadstoanabruptonsetofa
directCCfistula.Thisresultsinacuteonsetofmassiveexophthalmoswithorbital,
ocular,andconjunctivalchemosis,binoculardiplopia,andvisualloss.
TwotypesofCCfistulas
Directfistulaspresentwithprominentacutesymptoms.
Conversely,indirectfistulasarecharacterizedbymildproptosis,chronicdiplopia,
droopingofthelid,aredeye,arterializationoftheconjunctivalvessels,andvisualloss.
Thepatientmayreportsubjective"noises"inhisorherhead.
Cavernoussinusthrombosis
Thisisinfrequentinthepostantibioticera.
Itmayoccurasacomplicationofinfectionintheethmoid,sphenoid,orfrontalsinuses
orfrommidfacial,dental,ororbitalinfections.
Patientsmaypresentwithsepsisormetastaticspreadofsepticemboli,mostcommonly
occurringinthelung.Thispresentationmayappearasacuterespiratorydistress
syndrome(ARDS).
Retrobulbarpain,droopingoftheuppereyelid,anddiplopiamaybethefirstsymptoms
indicatingthelesion'sextensiontothecavernoussinus.
Miscellaneousinflammatorylesions
Thesemayinvolvethecavernoussinusesorthewallsofthesinus.
Herpeszosterinitsacuteorchronicstagerarelycausespain,diplopia,andadroopy
eyelidinadditiontothetypicalzosterblisters.Inthechronicstage,ascarfromthe
acutelesionusuallyisfound.
Anidiopathicinflammationofthewallsofthecavernoussinusesisreferredtoas
TolosaHuntsyndrome.
SarcoidorWegenergranulomatosismayalsopredisposetocavernoussinus
syndrome.

Physical
Seethelistbelow:
Cavernoussinuslesionsarecharacterizedbythefollowingsigns:
Unilateralandisolatedthird,fourth,orsixthcranialnervepalsy
Combinationpatternsofophthalmoplegia
Painfulophthalmoplegia
Proptosis(pulsatingexophthalmossuggestsadirectCCfistula)
Ocularandcranialbruits
Conjunctivalcongestionarterializationofconjunctivalveins
Ocularhypertension
Opticdiscedemaorpallorretinalhemorrhages
Anesthesiaintheophthalmicdivisionofthetrigeminalnerve(V1)and/ordecreasedor
absentcornealreflexandpossiblyanesthesiainthemaxillaryorV2branch
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Pupilinmidpositionandnonreactiveifbothsympatheticsandparasympatheticsfrom
thethirdnerveareaffected
Cavernoussinustumors
MetastaticlesionsIsolatedorcombinedophthalmoplegia,painfulophthalmoplegia,
anesthesiaintheophthalmicnerve
PituitarytumorsIsolatedorcombinedophthalmoplegia(lateralextension)endocrine
signssuchasacromegaly,galactorrhea,andunitemporalorbitemporalvisualfield
defects
PrimaryintracranialtumorsIsolatedorcombinedophthalmoplegiaand/orprimary
aberrantregenerationofthethirdcranialnerve
Cavernoussinusaneurysms
Isolatedorcombinedophthalmoplegia
Painfulophthalmoplegia
DecreasedpainsensationintheV1ophthalmicdivision
Carotidcavernousfistulas
DirectUnilateralmassiveproptosis,pulsatingexophthalmos,lidcongestion,
conjunctivalchemosis,orbitalcongestion,ocularhypertension,visualloss,optic
neuropathy,opticdiscedema,retinalhemorrhages,retinalvenouscongestion,andloud
ocularandcranialbruit
IndirectSimilarsignsandsymptomsoflesserseverityoccasionally,isolated
ophthalmoplegia,particularlyifthefistuladrainsposteriorly
Cavernoussinusthrombosis
Generallyspeaking,primaryinfectiousprocessinvolvingparanasalsinusesand/or
orbitalcellulitis
Inadditiontolocalandsystemicsignsofinfection,thefollowingmaybeseen:
Isolatedorcombinedophthalmoplegia
Painfulophthalmoplegia
Orbitalcongestion,lidchemosis,proptosis
Visualloss,opticdiscedema(unilateral)
Signsofmeningealirritation
Miscellaneouscavernoussinuslesions
TolosaHuntsyndromeIsolatedorcombined,painfulophthalmoplegia
HerpeszosterAcutezosterophthalmicus,typicalskinlesion,andkeratitis
SarcoidosisSystemicsigns,uveitis,ophthalmoplegia,facialdiplegia

Causes
Seethelistbelow:
Metastatictumors
Breast
Prostate
Lung
Localizedspreadoftumor
Nasopharyngeal
Pituitary
Primaryintracranialtumors
Meningiomas
Neurofibromas
Chondromas(lesscommon)
Trauma(includingpostsurgical)
Carotidcavernousaneurysms
Carotidcavernousfistulas
Cavernoussinusthrombosis
Miscellaneousinflammatorysyndromes
Herpeszoster
TolosaHuntsyndrome
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Sarcoidosis

DiagnosticWorkup
Patientsinwhomcavernoussinuslesionsaresuspectedshouldundergothinsectionmultiplanar
imagingstudiesoftheorbitandthesellar/parasellarregion.Precontrastandpostcontrastscans
areadvisable.CTscanoffersbettervisualizationofboneandcalcium.However,MRIprovides
betterdetailofallsofttissuescontainedinthesinuses,theexpectedsignalvoidofthenormal
carotidartery,anditsrelationtothesurroundingstructures.Seetheimagebelow.

AT1weighted,coronalMRI.

ViewMediaGallery
Orbitalviewsarenecessarytoexcludeadiseaseprocessprimarilyinvolvingthecavernous
sinuseswithconcomitantcompromiseoftheorbitalapex.Conversely,primaryorbitandparanasal
sinusdisordersfrequentlymayinvolvethecavernoussinuses.Visualizationofthesuperiorand
inferiororbitalveinsishelpfultodiagnoseincreasedvenouspressure.Onceimagingisobtained
andreviewedinlightofclinicalfindings,furtherinvestigationcanbepursuedtodeterminea
specificdiagnosis.

Cavernoussinustumors
Seethelistbelow:
Inthecaseofmetastatictumors,diagnosisoftheprimaryneoplasmgenerallyprecedesthe
cavernoussinussyndrome.
Alumbarpuncturewithcytologicexaminationmaybehelpful.
Ifaprimaryneoplasmofthenasopharynxissuspected,abiopsymaybeneeded.
Inthecaseofpituitarytumorswithlateralextension,tumorresectionmaybenecessary.
Rarely,abiopsyofthecavernoussinustumorisneededfordiagnosis.

Cavernoussinusaneurysms
Seethelistbelow:
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AsMRIand/ormagneticresonanceangiography(MRA)areoftenspecific,cerebral
angiographygenerallyisnotrequiredtomakeadiagnosis.
Performangiographyifballoonocclusionoftheaneurysmisplanned.

Carotidcavernousfistulas
Seethelistbelow:
ThedramaticclinicalpresentationandMRIand/orMRAofdirectfistulasleavelittledoubt
regardingthediagnosis.
Bycontrast,indirectfistulas,particularlythosedraininginthepetrosalsinuses,are
associatedwithsubtlefindingsandpossiblyanormalMRIand/orMRA.Seetheimages
below.

Thispatientisa55yearoldwomanwhooriginallyhadsymptomsofeyepainandpulsesynchronous
tinnitusontheleft.Shewasfoundtohaveanindirectleftcarotidcavernoussinusfistulaandunderwent
successfulcoilingofthefistula.Thispictureshowsheraftertheprocedure,asshehaddevelopedleft
eyechemosisanddiplopia.Aleftlateralrectusparalysiswaspresentonexamination.Inthiscase,the
probablecausesoftheophthalmoplegiacouldbemasseffectorocclusionofthevasanervorum
supplyingthesixthcranialnerve,whichtravelsintheadventitiaofthecarotidartery.Here,theprognosis
isexcellent,andtheauthorshaveseenseveralcaseswithimprovementwithin48weeksaftercoiling.

ViewMediaGallery

Earlyphaseofthepostfistulacoilingangiogramofthepatientshownabove.Coilscanbeappreciatedat
thecavernousportionofthecarotidartery.

ViewMediaGallery
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Laterfillingphaseoftheangiogramforthepatientshownabove.Notethatcoilinghasprevented
anomalousfillingofthecavernoussinusfistula.

ViewMediaGallery
Cerebralangiographyistheonlywaytoarriveatthecorrectdiagnosis.
Performangiographytostagethefistulaanddocumenttheanteriorandposteriordrainage
routes.

Cavernoussinusthrombosis
Seethelistbelow:
Imagingoftheorbitand/ornasalsinusesishelpfulinthesearchforasepticfocus.
Anasepticthrombosismaybeassociatedwithconditionssuchashypercoagulablestates
andlymphoproliferativedisorders.
Ahematologicworkupisindicatedinthesepatients.

Miscellaneousinflammatorysyndromes
Investigateadditionalsystemicinflammatoryandgranulomatousprocessesafterothercommon
causeshavebeenexcluded.Thesedisorderscanbescreenedbystudiessuchaslaboratorytests
andchestradiograph.
TolosaHuntsyndrome(anuncommon,idiopathic,inflammatorycavernoussinussyndrome)
mayshareacloseetiologiclinkwithorbitalpseudotumor.
Anonspecificfibroticinflammatoryreactionandrarelyagranulomatousinflammation
canoccur,butbiopsyisrarelyusedtoestablishthediagnosis.
Apositiveresponsetosteroidsisconsidereddiagnostic,butfalsepositiveresponses
canoccurinlymphomaandotherparasellarneoplasms.
Biopsyofthecavernoussinusesentailsacraniotomy,whichisassociatedwithmorbidity.
Restrictacraniotomytopatientswithadocumented,progressivecavernoussinussyndrome.

Treatment&Management
Cavernoussinustumors
Seethelistbelow:
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Metastaticlesions
Radiotherapymayoffertransientimprovement.
Nasopharyngealcarcinomasmaybeveryradiosensitive,withaprolongedremission
followingtreatment.
Pituitarytumors
Prolactinomasmayimprovewithoraldopamineagonists,ortheymayrequireresection.
Gammaknifemaybeanadjunctivetreatmentforpostoperativetumorresidualor
recurrenttumor,anditmayhavearoleasanalternativetoopensurgicaltreatment.
Cavernoussinusmeningiomas
Theselesionsrepresentamajorchallengeforsurgicalresection,primarilybecauseof
pooraccessibilityandthefrequentencasementofthecavernouscarotidartery.
Sincethesetumorsareslowgrowinganddifficulttoresect,elderlypatientsorthose
withminorsymptomsprobablyshouldbeobservedexpectantlywithoutspecific
treatment.
Radiotherapymaybeofferedtosomepatients,andsomeshowimprovementofcranial
nervefunctionaftergammaknifetreatment.Partialresectionmaybeattemptedin
otherswithdisablingsymptoms(eg,intractablepain,totalophthalmoplegiainapatient
withpoorvisioninthenonpareticeye).

Cavernoussinusaneurysms
Treatcavernoussinusaneurysmsbyendovascularballoonocclusion.

Carotidcavernousfistulas
Seethelistbelow:
Treatmentideallyconsistsofendovascularobliterationofthefistulawithcoils,althoughsome
cavernoussinusduralAVfistulasmaybeobservationallymanaged.
Accesstothefistulamaybetransarterialhowever,thetransvenousapproachhasbecome
themainstayoftreatment,insomecasesacombinedsurgical/endovascularapproachcan
beusedwithsurgicalexposureofthesuperiorophthalmicveinfollowedbyfistula
embolization.Severalvenousapproacheshavebeenused,includingthesafesttransfemoral
approachhowever,ifthisisnotfeasible,asuperiororbitalveinorapercutaneous
transorbitalpuncturetothecavernoussinuscanbeused.[3]
Supraorbitalveindissectionwithplacementofacathetertoaccessthecavernoussinuses
hasbeenperformedsuccessfully.
Percutaneoustransorbitalaccesstothecavernoussinusfollowedbyembolization.
SmallindirectCCfistulasmayoccludeeitherspontaneouslyorfollowingdiagnostic
angiography.Iftheclinicalsignsaremild,considercarefulmonitoring.
Ifintraocularpressureiselevated,antiglaucomaagentsmayberequired.

Cavernoussinusthrombosis
Seethelistbelow:
Highdoseantibiotictherapyshouldbedirectedagainstthemostcommonpathogens,such
asSaureusandSpneumoniae,aswellasgramnegativerodsandanaerobes.
Anticoagulationinsepticcavernoussinusthrombosisiscontroversial,butmayhastenthe
rateofrecovery.
Drainageofanyprimarysiteofinfection(eg,abscess,sinusitis)isadvised.
Corticosteroidsarenotrecommended.
Anticoagulationalsomaybehelpfulinasepticpatients.

Miscellaneousinflammatorysyndromes
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Seethelistbelow:
Inflammatorycavernoussinussyndromesmayrespondtotreatmentofthespecificsystemic
inflammationorvasculiticetiology.
TolosaHuntsyndromerespondswelltoa3to6monthcourseofhighdosesteroidtherapy
thatcanbetaperedslowlythereafter.
References

1.ShimizuY,TsutsumiS,YasumotoY,ItoM.Carotidcavernoussinusfistulacausedbydental
implantassociatedinfection.AmJOtolaryngol.2011Sep14.[Medline].
2.SheltonJB,RamakrishnaiahR,GlasierCM,PhillipsPH.Cavernoussinussyndromefroman
internalcarotidarteryaneurysminaninfantwithtuberoussclerosis.JAAPOS.2011Aug.
15(4):38991.[Medline].
3.WhiteJB,LaytonKF,EvansAJ,TongFC,JensenME,KallmesDF.Transorbitalpuncturefor
thetreatmentofcavernoussinusduralarteriovenousfistulas.AJNRAmJNeuroradiol.2007
Aug.28(7):14157.[Medline].
4.BoghenD,ChartrandJP,LaflammeP,etal.Primaryaberrantthirdnerveregeneration.Ann
Neurol.1979Nov.6(5):4158.[Medline].
5.BoneI,HadleyDM.Syndromesoftheorbitalfissure,cavernoussinus,cerebellopontine
angle,andskullbase.JNeurolNeurosurgPsychiatry.2005Sep.76Suppl3:iii29iii38.
[Medline].
6.BrazisPW,CapobiancoDJ,ChangFL,etal.Lowflowduralarteriovenousshunt:another
causeof"sinister"TolosaHuntsyndrome.Headache.1994Oct.34(9):5235.[Medline].
7.CampbellRJ,OkazakiH.Painfulophthalmoplegia(TolosaHuntvariant):autopsyfindingsin
apatientwithnecrotizingintracavernouscarotidvasculitisandinflammatorydiseaseofthe
orbit.MayoClinProc.1987Jun.62(6):5206.[Medline].
8.CannonML,AntonioBL,McCloskeyJJ,etal.Cavernoussinusthrombosiscomplicating
sinusitis.PediatrCritCareMed.2004Jan.5(1):868.[Medline].
9.DebrunG,LacourP,VinuelaF,etal.Treatmentof54traumaticcarotidcavernousfistulas.J
Neurosurg.1981Nov.55(5):67892.[Medline].
10.GreenbergHS,DeckMD,VikramB,etal.Metastasistothebaseoftheskull:clinicalfindings
in43patients.Neurology.1981May.31(5):5307.[Medline].
11.HedgesTR,LeungLS.Parasellarandorbitalapexsyndromecausedbyaspergillosis.
Neurology.1976Feb.26(2):11720.[Medline].
12.HouK,LuoQ,ChenQ,etal.Therapeuticembolizationofcavernoussinusdural
arteriovenousfistulasviatransvenousapproach.ChinMedJ(Engl).2003May.116(5):6614.
[Medline].
13.HuntWE,MeagherJN,LefeverHE,ZemanW.Painfulopthalmoplegia.Itsrelationtoindolent
inflammationofthecarvernoussinus.Neurology.1961Jan.11:5662.[Medline].
14.KattahJC,SilgalsRM,ManzH,etal.Presentationandmanagementofparasellarand
suprasellarmetastaticmasslesions.JNeurolNeurosurgPsychiatry.1985Jan.48(1):449.
[Medline].
15.KeaneJR.Cavernoussinussyndrome.Analysisof151cases.ArchNeurol.1996Oct.
53(10):96771.[Medline].
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02.12.2016

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16.KlineLB.TheTolosaHuntsyndrome.SurvOphthalmol.1982SepOct.27(2):7995.
[Medline].
17.KlineLB,HoytWF.TheTolosaHuntsyndrome.JNeurolNeurosurgPsychiatry.2001Nov.
71(5):57782.[Medline].
18.KuoJS,ChenJC,YuC,etal.Gammakniferadiosurgeryforbenigncavernoussinustumors:
quantitativeanalysisoftreatmentoutcomes.Neurosurgery.2004Jun.54(6):138593
discussion13934.[Medline].
19.KupersmithMJ,BerensteinA,ChoiIS,etal.Percutaneoustransvasculartreatmentofgiant
carotidaneurysms:neuroophthalmologicfindings.Neurology.1984Mar.34(3):32835.
[Medline].
20.LevineSR,TwymanRE,GilmanS.Theroleofanticoagulationincavernoussinus
thrombosis.Neurology.1988Apr.38(4):51722.[Medline].
21.MillerNR.Carotidcavernoussinusfistula.WalshandHoyt'sNeurophthalmology.4thed.
1991.Vol4:21652209.
22.SatomiJ,SatohK,MatsubaraS,etal.Angiographicchangesinvenousdrainageof
cavernoussinusduralarteriovenousfistulaeafterpalliativetransarterialembolizationor
observationalmanagement:aproposedstageclassification.Neurosurgery.2005Mar.
56(3):494502discussion494502.[Medline].
23.SchatzNJ,FarmerP.TolosaHuntsyndrome:Thepathologyofpainfulophthalmoplegia.
NeurophthalmologySymposiumoftheUniversityofMiami&BascomPalmerEyeInstitute.
1972.102112.
24.ThomasJE,YossRE.Theparasellarsyndrome:problemsindeterminingetiology.MayoClin
Proc.1970Sep.45(9):61723.[Medline].
25.ZweiflerRM.Managementofacutestroke.SouthMedJ.2003Apr.96:3805.[Medline].
MediaGallery

Carotidcavernousfistula.

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AT1weighted,coronalMRI.

Thispatientisa55yearoldwomanwhooriginallyhadsymptomsofeyepainandpulse
synchronoustinnitusontheleft.Shewasfoundtohaveanindirectleftcarotidcavernous
sinusfistulaandunderwentsuccessfulcoilingofthefistula.Thispictureshowsherafterthe
procedure,asshehaddevelopedlefteyechemosisanddiplopia.Aleftlateralrectus
paralysiswaspresentonexamination.Inthiscase,theprobablecausesofthe
ophthalmoplegiacouldbemasseffectorocclusionofthevasanervorumsupplyingthesixth
cranialnerve,whichtravelsintheadventitiaofthecarotidartery.Here,theprognosisis
excellent,andtheauthorshaveseenseveralcaseswithimprovementwithin48weeksafter
coiling.

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Earlyphaseofthepostfistulacoilingangiogramofthepatientshownabove.Coilscanbe
appreciatedatthecavernousportionofthecarotidartery.

Laterfillingphaseoftheangiogramforthepatientshownabove.Notethatcoilinghas
preventedanomalousfillingofthecavernoussinusfistula.
of5

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ContributorInformationandDisclosures

Author
JorgeCKattah,MDHead,AssociateProgramDirector,Professor,DepartmentofNeurology,
UniversityofIllinoisCollegeofMedicineatPeoria
JorgeCKattah,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Neurology,AmericanNeurologicalAssociation,NewYorkAcademyofSciences
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Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedical
CenterCollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
RobertAEgan,MDNWNeuroOphthalmology
RobertAEgan,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Neurology,AmericanHeartAssociation,NorthAmericanNeuroOphthalmologySociety,Oregon
MedicalAssociation
Disclosure:ReceivedhonorariafromBiogenIdecforspeakingandteachingReceivedhonoraria
fromTevaforspeakingandteaching.
ChiefEditor
RobertAEgan,MDNWNeuroOphthalmology
RobertAEgan,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Neurology,AmericanHeartAssociation,NorthAmericanNeuroOphthalmologySociety,Oregon
MedicalAssociation
Disclosure:ReceivedhonorariafromBiogenIdecforspeakingandteachingReceivedhonoraria
fromTevaforspeakingandteaching.
AdditionalContributors
DragaJichici,MD,FRCP,FAHAAssociateClinicalProfessor,DepartmentofNeurologyand
CriticalCareMedicine,McMasterUniversitySchoolofMedicine,Canada
DragaJichici,MD,FRCP,FAHAisamemberofthefollowingmedicalsocieties:American
AcademyofNeurology,RoyalCollegeofPhysiciansandSurgeonsofCanada,CanadianMedical
ProtectiveAssociation,CanadianMedicalProtectiveAssociation,NeurocriticalCareSociety,
CanadianCriticalCareSociety,CanadianCriticalCareSociety,CanadianNeurocriticalCare
Society,CanadianNeurologicalSciencesFederation
Disclosure:Nothingtodisclose.
Acknowledgements
JohnHPula,MDStaffPhysician,DepartmentofNeurology,OSFSaintFrancisMedicalCenter,
UniversityofIllinoisCollegeofMedicineatPeoria
Disclosure:Nothingtodisclose.
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