Endocrinol Metab.  2011 Dec;26(4):335-339. 10.3803/EnM.2011.26.4.335.

Ophthalmopathy Induced by Bilateral Carotid Cavernous Fistula in a Patient with Graves' Disease

• Ha JK
• Suk JH
• Jo AR
• Jung CW
• Kim BJ
• Park SO
• Kim SS
• Kim MK

• KMID: 2169265
• DOI: http://doi.org/10.3803/EnM.2011.26.4.335

Abstract

Graves' disease (GD) can lead to specific eye afflictions including proptosis, periorbital swelling, conjunctival injection, chemosis, and opthalmoplegia, which then become a condition called Graves' ophthalmopathy or thyroid-associated ophthalmopathy (TAO). A carotid cavernous fistula (CCF) is an abnormal vascular communication between the carotid artery and the cavernous sinus. The clinical signs of CCF are very similar to TAO and should be considered as a differential diagnosis of TAO. We would like to present an interesting case of a bilateral ophthalmopathy induced by CCF in a GD patient. A 54-year-old man with a 6-year history of GD presented with bilateral exophthalmos and conjunctival injection for two months. The orbital CT scan findings were consistent with CCF, and an angiography revealed bilateral CCF. He received a bilateral coil embolization for the CCF and his ophthalmic signs were immediately improved. We recommend orbital imaging to exclude other coexisting diseases in patients who are suspected of TAO, especially when the diagnosis is uncertain or when determining whether medical or surgical intervention is appropriate.

Keyword

Carotid cavernous fistula; Graves' disease; Ophthalmopathy

MeSH Terms

Angiography
Carotid Arteries
Cavernous Sinus
Caves
Diagnosis, Differential
Exophthalmos
Eye
Fistula
Graves Disease
Graves Ophthalmopathy
Humans
Middle Aged
Orbit
Troleandomycin
Troleandomycin

Figure

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  Fig. 1 Ocular manifestations of the patient. A. Before embolization treatment, the patient presented bilateral proptosis, periorbital edema, conjunctival injection and chemosis. B. After embolization treatment, conjunctival injection and chemosis disappeared, bilateral proptosis was improved.

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  Fig. 2 Before embolization treatment. Orbital computed tomography revealed dilated left superior ophthalmic vein (white arrow, A) and dilated left cavernous sinus (Black arrow, B).

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  Fig. 3 Cerebral angiography. A. Before embolization treatment, anteroposterial projection, demonstrating the supply to the bilateral carotid cavernous fistula from both branches of external carotid artery and meningeal branches of internal carotid artery. B. Embolization was performed with venous approach at both cavernous sinuses and intercavernous sinus. C. After embolization treatment, anteroposterial projection, showing complete occlusion of bilateral carotid cavernous fistula.

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