In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Prediction of Traumatic Carotid-Cavernous Sinus Fistula via Non-Contrast CT by Fracture Pattern and Abnormality of Venous System

    Final Number:

    Lin Tzu-Chin

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Traumatic carotid-cavernous fistula (tCCF) is infrequent but with high morbidity if delayed diagnosed or managed. The diagnosis is mainly achieved by clinical suspicion and confirmed by radiological modalities. Due to lack of screening criteria and requirement of advanced and invasive radiological examinations, diagnosis is often delayed or underdiagnosed.

    Methods: Patients with craniofacial trauma in a tertiary referral center were included from January 2004 to December 2014 and selected by International Classification of Diseases, Ninth Revision code 900.82 with confirmation by angiography. A matched case-control study with univariate and multivariate analysis was conducted to predict tCCFs. Forty-six patients diagnosed with tCCFs were included and matched with 138 patients of craniofacial trauma without tCCF as control at a ratio of 1:3. To eliminate the bias, two cohorts were matched according to age, gender, Abbreviated Injury Scale (AIS) of head and face, and Injury Severity Score (ISS).

    Results: The diagnostic diameter of superior ophthalmic vein (SOV) in tCCF was 4 mm with area under curve of 0.89. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 71.4%, 92.1%, 81.1%, and 87.2%, respectively. In multivariate analysis, engorgement of SOV and cavernous sinus (CS) (OR: 35.39, p < 0.001) and lateral impact (ipsilateral temporal and sphenoid sinus fractures) (OR: 3.96, p = 0.028) were identified significant, whereas basilar skull fracture (OR: 1.58, p = 0.300) and injuries to ocular nerves (CN III, IV, and VI) (OR: 1.77, p = 0.055) were insignificant.

    Conclusions: Presence of SOV or CS engorgement and lateral impact predict were demonstrated as independent predictors to tCCF and warrant further radiological evaluation. Injury to ocular nerves is not predictive but as an essential differential diagnosis with reversible outcome.

    Patient Care: Among examination of non-contrast CT, presence of superior ophthalmic vein (SOV) (> 4mm) or cavernous sinus (CS) engorgement predicts development of traumatic carotid-cavernous fistula (tCCF) robustly. Lateral impact (ipsilateral temporal and sphenoid sinus fractures) also demonstrated as an independent predictor. Further radiological evaluation is warrant in presence of SOV or CS engorgement or lateral impact correlated with suspicious ophthalmic symptoms.

    Learning Objectives: In order to provide a guide for trauma clinician to detect tCCFs timely in the population of craniofacial trauma.

    References: 1. Fattahi, T. T., Brandt, M. T., Jenkins, W. S. & Steinberg, B. Traumatic carotid-cavernous fistula: pathophysiology and treatment. J. Craniofac. Surg. 14, 240–6 (2003). 2. Liang, W. et al. Traumatic Carotid Cavernous Fistula Accompanying Basilar Skull Fracture: a Study on the Incidence of Traumatic Carotid Cavernous Fistula in the Patients With Basilar Skull Fracture and the Prognostic Analysis About Traumatic Carotid Cavernous Fistula. J. Trauma Inj. Infect. Crit. Care 63, 1014–1020 (2007). 3. Albuquerque, F. C., Heinz, G. W. & McDougall, C. G. Reversal of blindness after transvenous embolization of a carotid-cavernous fistula: case report. Neurosurgery 52, 233–237 (2003). 4. Kamel, H. A. M., Choudhari, K. A. & Gillespie, J. S. J. Bilateral traumatic caroticocavernous fistulae: total resolution following unilateral occlusion. Neuroradiology 42, 462–465 (2000). 5. Chen, C. C.-C., Chang, P. C.-T., Shy, C.-G., Chen, W.-S. & Hung, H.-C. CT angiography and MR angiography in the evaluation of carotid cavernous sinus fistula prior to embolization: a comparison of techniques. Am. J. Neuroradiol. 26, 2349–2356 (2005). 6. Mundinger, G. S. et al. Blunt-mechanism facial fracture patterns associated with internal carotid artery injuries: Recommendations for additional screening criteria based on analysis of 4,398 patients. J. Oral Maxillofac. Surg. 71, 2092–2100 (2013). 7. Bromberg, W. J. et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J. Trauma 68, 471–477 (2010). 8. Franz, R. W., Willette, P. A., Wood, M. J., Wright, M. L. & Hartman, J. F. A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries. J. Am. Coll. Surg. 214, 313–327 (2012). 9. Ahmadi, J. et al. Computed tomography of carotid-cavernous fistula. AJNR. Am. J. Neuroradiol. 4, 131–6 (1983). 10. Jimenez, D. F., Sundrani, S. & Barone, C. M. Posttraumatic anosmia in craniofacial trauma. J. Craniomaxillofac. Trauma 3, 8–15 (1996). 11. Lin, T.-C. et al. Systematic Analysis of the Risk Factors Affecting the Recurrence of Traumatic Carotid-Cavernous Sinus Fistula. World Neurosurg. 90, 539–545.e1 (2016). 12. Cantini Ardila, J. E., Mendoza, M. Á. R. & Ortega, V. G. Sphenoid sinus and sphenoid bone fractures in patients with craniomaxillofacial trauma. Craniomaxillofac. Trauma Reconstr. 6, 179–86 (2013). 13. Craig, J. & Goyal, P. Patterns and sequelae of sphenoid sinus fractures. Am J Rhinol Allergy 29, 211–214 (2015). 14. Sun, G. H. et al. Do contemporary temporal bone fracture classification systems reflect concurrent intracranial and cervical spine injuries? Laryngoscope 121, 929–932 (2011). 15. Chang, C., Chen, Y., Noordhoff, S. & Chang, C. Maxillary involvement in central craniofacial fractures with associated head injuries. J. Trauma Acute Care Surg. 37, 807–811 (1994). 16. Lee, K. F., Wagner, L. K., Lee, Y. E., Suh, J. H. & Lee, S. R. The impact-absorbing effects of facial fractures in closed-head injuries: An analysis of 210 patients. J. Neurosurg. 66, 542–547 (1987). 17. Post, A. et al. Traumatic brain injuries: The influence of the direction of impact. Neurosurgery 76, 81–91 (2015). 18. Rhoton, A. L. The orbit. Neurosurgery 51, 303–334 (2002). 19. Martins, C. et al. Microsurgical anatomy of the orbit: the rule of seven. Anat. Res. Int. 2011, (2010). 20. Spektor, S., Piontek, E. & Umansky, F. Orbital venous drainage into the anterior cavernous sinus space; microanatomic relationships. Neurosurgery 40, 532–540 (1997). 21. Lirng, J. F., Fuh, J. L., Wu, Z. A., Lu, S. R. & Wang, S. J. Diameter of the superior ophthalmic vein in relation to intracranial pressure. Am. J. Neuroradiol. 24, 700–703 (2003). 22. Khanna, R. K. et al. Bilateral superior ophthalmic vein enlargement associated with diffuse cerebral swelling. Report of 11 cases. J. Neurosurg. 86, 893–7 (1997). 23. Dhaliwal, A., West, A. L., Trobe, J. D. & Musch, D. C. Third, fourth, and sixth cranial nerve palsies following closed head injury. J. Neuro-Ophthalmology 26, 4–10 (2006). 24. Coello, A. F., Canals, A. G., Gonzalez, J. M. & Martín, J. J. A. Cranial nerve injury after minor head trauma. J. Neurosurg. 113, 547–555 (2010). 25. Fujisawa, H. et al. Abducens nerve palsy and ipsilateral Horner syndrome: a predicting sign of intracranial carotid injury in a head trauma patient. J Trauma 50, 554–556 (2001). 26. Chen, C.-T. et al. Traumatic superior orbital fissure syndrome: assessment of cranial nerve recovery in 33 cases. Plast. Reconstr. Surg. 126, 205–12 (2010). 27. Team, R. C. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2013. (2014).

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy