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Carotid Artery - Cavernous Sinus Fistula

(Carotid-Cavernous Fistula, CCF)

A fracture at the base of the skull can cause the formation of a fistula between the large basal artery (internal carotid artery) and large basal sinus which is difficult to demonstrate at autopsy. Fistulas are most often caused by mechanically induced (less often spontaneous) tears in the carotid artery (see Lewis et al. 1995: 76 of 100 cases). Injury often results from stretching or tearing of the basilar vessels, though such fistulas are found in only about 5% of fronto-basal fractures (Schima 1961; Isfort 1965). A large Korean study (Chung et al. 2002) found the cavernous sinus to be the most common location. Other causes included craniotomy, sinus thrombosis, acupuncture, or cerebral infarction (Chung et al. 2002).

Clinical Features. Patients report hearing intracra-nial noises. The classic objective symptom is a pulsating exophthalmos, regarded to be a firm criterion of an abnormal connection between the internal carotid artery and the cavernous sinus (Friedmann et al. 1970). At times, protrusion of both ocular globes (Kupersmith et al. 1986) and/or an orbital bruit (80%), proptosis (72%), chemosis (55%), etc. (Lewis et al. 1995) have also been reported.

Morphology. The fistula can be easily visualized using angiography. For autopsy the technique described by Krauland (1982) is recommended: the

Fig. 7.26. Mechanically induced carotid-cavernous fistula, i.e., a single hole communication between the carotid artery and the cavernous venous sinus. At autopsy a characteristic marker will be the orbital chemosis caused by a conjunctival vascular enlargement and exposure ophthalmitis

roof of the cavernous sinus is split to allow outward opening of both the side wall and the anterior clinoid process. Any signs of hemorrhage in the adventitia of the vessel are to be regarded as indicating damage to the vessel wall. Moreover, in single cases, orbital chemosis is visible, also at autopsy, secondary to the conjunctival vascular enlargement and exposure ophthalmitis (Fig. 7.26). Splitting of the vessel wall will expose any tears in the intima. Death can result from loss of blood through the nose, mouth and/or ears, or from aspiration of blood.

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