Giant intracavernous carotid aneurysm after spontaneous thrombosis of a carotid cavernous sinus fistula.

A 40-year-old woman was admitted to a local hospital following the acute onset of severe right temporal and retroorbital headache associated with nausea and vomiting. For 2 or 3 days before the onset of symptoms she had experienced a flulike illness with repeated episodes of coughing. She also had a mild temperature elevation. Her past medical history was unremarkable. At the time of initial examination she was alert and complained of severe headache. There was slight restriction of her neck movements and she complained of a noise in her right ear. On examination a bruit was heard over the right temporal area. No visual signs or symptoms were present, and there were no focal neurologic abnormalities. She was admitted to the hospital with an initial diagnosis of subarachnoid hemorrhage resulting from rupture of an intracranial aneurysm. Angiography done the same day revealed a high-flow right internal carotid artery to cavernous sinus fistula (Fig. 1). During the next 24 hr the patient developed striking proptosis, chemosis, and loss of vision in the right eye. She was transferred to the University of Wisconsin Center for Health Sciences for balloon occlusion of her carotid cavernous sinus fistula. Upon arrival she was restless and complained of severe right orbital pain. Her blood pressure was 130/90 and her temperature was 37.7°C. Examination revealed severe proptosis, chemosis, and conjunctival erythema of the right eye, which had no light perception. Visual acuity was 20/20 in the left eye. Extraocular motility of the right eye was severely restricted in all directions. Ocular motility was normal on the left. The intraocular pressure was greater than 60 mm Hg 0.0. and 8 mm Hg O.S. No bruit could be heard either over the right orbit or over the right temporal area. Repeat angiography revealed a slow flow carotid cavernous sinus fistula with evidence of thrombus within the cavernous sinus and superior ophthalmic vein (Fig. 2). Dilatation and abnormally slow flow in the inferior and posterior draining veins from the cavernous sinus was also noted. Attempts to enter the cavernous sinus with a detachable balloon catheter failed. Because of the evidence of spontaneous thrombosis and the fact that the right eye was judged to have irreversible visual loss, a trapping procedure was not performed. Over the next 48 hr the patient continued to complain of severe right orbital pain. She developed partial palSies of the 7th, 11 th, and 12th cranial nerves. With only symptomatic treatment these symptoms as well as the proptosis and chemosis resolved , and on the 10th day after admission she was discharged. At this time she was without pain and showed complete retinal infarction.