UNUSUAL UNUSUAL CAROTID CAVERNOUS CAROTID CAVERNOUS

SINUS SINUS FISTULAFISTULA

ANIL KARAPURKARANIL KARAPURKARSir H N HOSPITALSir H N HOSPITAL

MUMBAIMUMBAI

CCFCCF►BARROW CLASSIFICATIONBARROW CLASSIFICATION►TYPE A : DIRECT ICA-CAV. SINUSTYPE A : DIRECT ICA-CAV. SINUS►TYPE B : BRANCHES OF ICA TO CAV. TYPE B : BRANCHES OF ICA TO CAV.

SINSIN►TYPE C : BRANCHES OF ECA TO CAV. TYPE C : BRANCHES OF ECA TO CAV.

SINSIN►TYPE D: BR. OF ICA & ECA TO CAV TYPE D: BR. OF ICA & ECA TO CAV

SINUSSINUS

V V V V ►GRADUAL ONSET SLOWLY GRADUAL ONSET SLOWLY

PROGRESSIVE BILATERAL PROPTOSISPROGRESSIVE BILATERAL PROPTOSIS►CONJUNCTIVAL EDEMA, CHEMOSISCONJUNCTIVAL EDEMA, CHEMOSIS►BRUIT IN THE HEADBRUIT IN THE HEAD

VVVV

VVVV

V VV V

►FOLLOWING CORRECTION OF FOLLOWING CORRECTION OF COARCTATIONCOARCTATION

►LEFT CAROTID- AORTIC BYPASSLEFT CAROTID- AORTIC BYPASS

VVVV

AFTER CORRECTION OF COARCT

R P GR P G►RTARTA►UNCONSCIOUS SINCE ACCIDENTUNCONSCIOUS SINCE ACCIDENT►RIGHT SIDED CHEMOSIS, RIGHT SIDED CHEMOSIS,

OPHTHALMOPLEGIAOPHTHALMOPLEGIA►NO BRUIT OVER EYEBALLNO BRUIT OVER EYEBALL

R P G R P G Which artery ?

R P GR P G

COILING

B SB S►10 YEARS OLD RIGHT HANDED BOY 10 YEARS OLD RIGHT HANDED BOY

FROM ORISSA, EASTERN INDIAFROM ORISSA, EASTERN INDIA►SUDDEN ONSET SEVERE LEFT ORBITAL SUDDEN ONSET SEVERE LEFT ORBITAL

PAIN FOLLOWED BY SEVERE PAIN FOLLOWED BY SEVERE PROPTOSIS, CHEMOSISPROPTOSIS, CHEMOSIS

►SICK LOOKING PATIENTSICK LOOKING PATIENT

B SB S

CT Scan showing huge cavernous sinus & CCF

B SB S

B SB S

MASSIVE ECA SUPPLY – DURAL AVF

B SB S

Dural AVF right cavernous sinus

B SB S

ARTERIAL ANEURYSM ON LEFT SCA

B SB S

Excellent cross flow via AComm & PComm

B SB S►NO TREATMENT NO TREATMENT ►FAMILY TOOK PATIENT AWAYFAMILY TOOK PATIENT AWAY

B SB S► H/O RTAH/O RTA► SMALL CAR TELESCOPED UNDER REAR OF SMALL CAR TELESCOPED UNDER REAR OF

TRUCK IN WINTER FOG ON 1TRUCK IN WINTER FOG ON 1STST JAN JAN ► TOP OF MARUTI SHEARED OFFTOP OF MARUTI SHEARED OFF► SEVERE HEAD INJURYSEVERE HEAD INJURY► RIGHT TEMPORO FRONTAL COMPOUND RIGHT TEMPORO FRONTAL COMPOUND

DEPRESSED FRACTUREDEPRESSED FRACTURE► BRAIN HERNIABRAIN HERNIA► SEVERE ENT HEMORRHAGESEVERE ENT HEMORRHAGE► NASAL PACKING BOTH NOSTRILSNASAL PACKING BOTH NOSTRILS

B SB S►CT SCANCT SCAN►EXTENSIVE SAH, BRAIN EDEMAEXTENSIVE SAH, BRAIN EDEMA►FRACTURE GREATER & LESSER WING FRACTURE GREATER & LESSER WING

SPHENOID, ORBITSPHENOID, ORBIT►FRACTURE ANTERIOR CLINOIDFRACTURE ANTERIOR CLINOID►CAROTID INJURY SUSPECTEDCAROTID INJURY SUSPECTED►DSA DONEDSA DONE

B SB S

GOOD CROSS FLOW VIA AComm, PComm

FALSE ANEURYSM, SEVERE SPASM

B SB S►NASAL PACK LEFT IN PLACENASAL PACK LEFT IN PLACE► IN VIEW OF SPASM NO TREATMENT IN VIEW OF SPASM NO TREATMENT

FOR ANEURYSMFOR ANEURYSM►CRANIOTOMY FOR REPAIR OF DURACRANIOTOMY FOR REPAIR OF DURA►CARE TAKEN NOT TO FOLLOW CARE TAKEN NOT TO FOLLOW

FRACTURE OF ANT. CLINOIDFRACTURE OF ANT. CLINOID►ELECTIVE VENTILATION FOR 3 DAYSELECTIVE VENTILATION FOR 3 DAYS

B SB S►NASAL PACK REMOVED ON DAY3 NASAL PACK REMOVED ON DAY3

FROM LEFT NOSTRILFROM LEFT NOSTRIL►RIGHT NOSTRIL REPACKED AS THERE RIGHT NOSTRIL REPACKED AS THERE

WAS PERSISTENT OOZEWAS PERSISTENT OOZE►PATIENT WEANED OFF VENTILATORPATIENT WEANED OFF VENTILATOR►CONSCIOUS, OBEYING COMMANDSCONSCIOUS, OBEYING COMMANDS

B SB S►DAY 4 SUDDEN INCREASE IN DAY 4 SUDDEN INCREASE IN

PROPTOSIS, CONJUNCTIVAL INJECTION, PROPTOSIS, CONJUNCTIVAL INJECTION, CHEMOSISCHEMOSIS

►LATER IN THE DAY RECURRENT H’AGE LATER IN THE DAY RECURRENT H’AGE FROM RIGHT NOSTRIL DESPITE PACKFROM RIGHT NOSTRIL DESPITE PACK

►ANTERIOR & POSTERIOR PACKING OF ANTERIOR & POSTERIOR PACKING OF BOTH NOSTRILS DONEBOTH NOSTRILS DONE

B SB S►DAY 5 SEVERE RECURRENT H’AGE DAY 5 SEVERE RECURRENT H’AGE

DESPITE PREVIOUS PACKINGDESPITE PREVIOUS PACKING►REPACKING ATTEMPTED TO NO AVAILREPACKING ATTEMPTED TO NO AVAIL►GOT RESIDENT TO COMPRESS GOT RESIDENT TO COMPRESS

CAROTID IN NECKCAROTID IN NECK►WITH PRESSURE MAINTAINED PATIENT WITH PRESSURE MAINTAINED PATIENT

SHIFTED TO DSASHIFTED TO DSA

B SB S

CCF AT SITE OF ANEURYSM

B SB S

PRESSURE ON CAROTID CONTINUED EVEN AFTER BALLOON INFLATED, NOTE CCF DRANING VEIN

B SB S

H’AGE STOPPED ONLY AFTER FULL INFLATION OF BALLOON

B SB S►PATIENT TOLERATED OCCLUSIONPATIENT TOLERATED OCCLUSION►MILD LEFT HEMIPARESIS PERSISTEDMILD LEFT HEMIPARESIS PERSISTED

F KF K►70 YEARS OLD RIGHT HANDED MALE70 YEARS OLD RIGHT HANDED MALE►6’ PLUS GANGSTER OF WESTERN UP 6’ PLUS GANGSTER OF WESTERN UP ►SHOT IN THE NECKSHOT IN THE NECK►BULLET ENTERED FROM LEFT EXITED BULLET ENTERED FROM LEFT EXITED

FROM RIGHTFROM RIGHT►ENTRY EXIT WOUNDS PACKEDENTRY EXIT WOUNDS PACKED►PATIENT TRANSFERRED TO OUR PATIENT TRANSFERRED TO OUR

HOSPITALHOSPITAL

F KF K►PLASTIC SURGEON EXPLORED RIGHT PLASTIC SURGEON EXPLORED RIGHT

WOUND FIRSTWOUND FIRST►PROFUSE H’AGE COULD DO NOTHING PROFUSE H’AGE COULD DO NOTHING

REPACKEDREPACKED►EXPLORED LEFT WOUND AGAIN EXPLORED LEFT WOUND AGAIN

PROFUSE H’AGE, REPACKEDPROFUSE H’AGE, REPACKED►REFERRED FOR OPINIONREFERRED FOR OPINION►DSA ADVISEDDSA ADVISED

B SB S

CCF WITH DRAINAGE INTO NECK VEINS ON BOTH SIDES

B SB S

GOOD CROSS FLOW VIA PComm, AComm

B SB S

BALLOON OCCLUSION

PACK REMOVED, NO H’AGE

DISCHARGED NEXT DAY

R UR U►8 YEARS OLD BOY8 YEARS OLD BOY►HIGH FEVERHIGH FEVER►PROPTOSIS, CHEMOSIS, PROPTOSIS, CHEMOSIS,

CONJUNCTIVAL EDEMACONJUNCTIVAL EDEMA►LOUD BRUITLOUD BRUIT►SEPTIC THROMBOPHLEBITIS OF ORBITSEPTIC THROMBOPHLEBITIS OF ORBIT

R UR U

Treatment planned for next dayDied during the night

A GA G►PREVIOUSLY DOCUMENTED PREVIOUSLY DOCUMENTED

ANEURYSM RUPTURING INTO ANEURYSM RUPTURING INTO CAVERNOUS SINUSCAVERNOUS SINUS

A GA G►46 YEARS OLD FEMALE PATIENT46 YEARS OLD FEMALE PATIENT►SUDDEN ONSET LATERAL RECTUS SUDDEN ONSET LATERAL RECTUS

PALSYPALSY►FOUND TO HAVE BILATERAL FOUND TO HAVE BILATERAL

ANEURYSMS OF CAVERNOUS ICAANEURYSMS OF CAVERNOUS ICA►TREATED FOR RIGHT SIDED TREATED FOR RIGHT SIDED

ANEURYSM WITH OCCLUSION COILS ANEURYSM WITH OCCLUSION COILS AT ANOTHER HOSPITALAT ANOTHER HOSPITAL

A GA G►PRESENT HISTORYPRESENT HISTORY►SUDDEN ONSET SPONTANEOUS SUDDEN ONSET SPONTANEOUS

PROTOSIS, CHEMOSIS, CONJUNCTIVAL PROTOSIS, CHEMOSIS, CONJUNCTIVAL INJECTIONINJECTION

►LOUD BRUIT OVER EYEBALLLOUD BRUIT OVER EYEBALL

A GA G

LEFT CCF

B SB S

COILS ON RIGHT

BALLOON ON LEFT

N TN T► ROAD TRAFFIC ACCIDENTROAD TRAFFIC ACCIDENT► ORBITAL INJURY, CHEMOSIS, ECCHYMOSISORBITAL INJURY, CHEMOSIS, ECCHYMOSIS► 2 MONTHS LATER SUDEEN ONSET RAPIDLY 2 MONTHS LATER SUDEEN ONSET RAPIDLY

PROGRESSIVE PROTPOSISPROGRESSIVE PROTPOSIS► CONJUNCTIVAL INJECTIONCONJUNCTIVAL INJECTION► LOUD BRUIT OVER EYEBALL SYNCHRONOUS LOUD BRUIT OVER EYEBALL SYNCHRONOUS

WITH PULSEWITH PULSE► BRUIT DISAPPEARS ON CAROTID BRUIT DISAPPEARS ON CAROTID

COMPRESSIONCOMPRESSION

N TN T

DILATED OPHTHALMIC VEIN CAVERNOUS SINUS

N TN T

TYPE A CCF

N TN T

ANEURYSM SEEN AFTER OCCLUSION OF CCF

N TN T►ANEURYSM MAY RUPTURE AFTER ANEURYSM MAY RUPTURE AFTER

TREATMENT OF HIGH FLOW CCFTREATMENT OF HIGH FLOW CCF► ICA THEREFORE OCCLUDEDICA THEREFORE OCCLUDED

ISKISK►RTA 1 MONTH EARLIERRTA 1 MONTH EARLIER► INJURY TO LEFT ORBITINJURY TO LEFT ORBIT►COMPLETE OPHTHALMOPLEGIACOMPLETE OPHTHALMOPLEGIA►GRADUAL REGRESSION OF CHEMOSISGRADUAL REGRESSION OF CHEMOSIS►REAPPEARANCE OF PROPTOSIS WITH REAPPEARANCE OF PROPTOSIS WITH

CONJUNCTIVAL INJECTIONCONJUNCTIVAL INJECTION►LOUD BRUITLOUD BRUIT

I S KI S K

I S KI S K

2nd HOLE CCF SEEN AFTER FIRST CLOSED

I S KI S K

FOLLOW UP 1 MO. LATER

2 GIANT ANEURYSMS COMPRESSING ICA

I S KI S K

TEST OCCLUSION

PERMANENT OCCLUSION

S M BS M B►GRADUAL ONSET PROPTOSISGRADUAL ONSET PROPTOSIS►PROGRESSIVE SINCE 4 MONTHSPROGRESSIVE SINCE 4 MONTHS►DIMINISHED VISIONDIMINISHED VISION►BRUIT OVER EYEBALLBRUIT OVER EYEBALL

S M BS M B

S M BS M B

A-V FISTULA OF PETROUS APEX DRAINING INTO OPHTHALMIC VEINS

S SS S►RTA SEVERAL YEARS AGORTA SEVERAL YEARS AGO►LEFT SIDED CCF LEFT SIDED CCF ►TREATED AT ANOTHER HOSPITAL TREATED AT ANOTHER HOSPITAL

MANY YEARS AGOMANY YEARS AGO►RECURRENT PROPTOSIS, DIMINSHED RECURRENT PROPTOSIS, DIMINSHED

VISIONVISION

S SS S

S SS S

S SS S

GLUE + COILS

A SA S

CCF ON LEFT ICA, PROPTOSIS ON RIGHT

UNUSUAL CCFUNUSUAL CCF►CONCLUSIONCONCLUSION►CAREFUL PLANNING REQUIREDCAREFUL PLANNING REQUIRED►COMPLETE ANGIOGRAPHYCOMPLETE ANGIOGRAPHY►LOOK AT COMPETITION BETWEEN LOOK AT COMPETITION BETWEEN

VENOUS DRAINAGE OF BRAIN & CCFVENOUS DRAINAGE OF BRAIN & CCF►ATERIAL OR VENOUS ROUTEATERIAL OR VENOUS ROUTE►COMBINATION OF COILS, GLUE OR COMBINATION OF COILS, GLUE OR

ONYX FOR COMPLEX CCFONYX FOR COMPLEX CCF