The team of surgeons at Apollo Speciality Hospital, OMR performed a first-of-its-kind, rare surgery on a 58-year-old lady who sustained traumatic injuries in a car accident and was suffering from severe brain contusions and multiple fractures of the skull base bones.
During the initial course of treatment at a city hospital, Ms. Lalitha regained consciousness but suffered from double vision and vision detonation, in addition to excessive swelling, redness and excessive water discharge (tears) from both eyes. She was referred to Apollo Speciality Hospitals, OMR where the ophthalmological evaluation presented restricted eye movements and very high eye pressure (Intra ocular pressure).
On observing conjunctival redness and swelling in the eyes and an audible orbital bruit (A sound over the eyeball, better heard using a stethoscope) Dr. Joy Varghese, Senior Consultant, Neuro Surgeon & Interventionist, Apollo Speciality Hospitals, OMR suspected that it could be the result of a carotid cavernous fistula, particularly when he noticed the abnormal protrusion of the eye ball (exophthalmos). After clinical and radiological evaluation, the condition was diagnosed as ‘bilateral direct carotid cavernous fistula’ – an abnormal connection between artery and vein that can raise the pressure inside the veins of the eyeball and brain, damaging both the organs.
A ‘carotid cavernous fistula’ is an abnormal connection between an artery in the neck supplying blood to the brain (carotid artery), to a network of veins at the back of eye called the cavernous sinus. The veins in the back of eye normally take away blood from the eye and brain, to the heart through a small specified channel called cavernous sinus. However, an accidental tear of a segment of the carotid artery which lies closer to the cavernous sinus (as happened in this particular case) can cause an abnormal connection between the artery and the venous sinus (cavernous sinus) ending up in carotid cavernous fistula. This abnormal connection between artery and vein raises the pressure inside the veins of eyeball and brain, damaging both the organs.
The medical team at Apollo Hospitals made a prompt diagnosis and an early intervention to save the patient. Trans Arterial Embolisation surgery was performed by Dr Joy Varghese and the team at Apollo Speciality Hospitals, OMR to save the patient.
Dr Joy Varghese said, “Selective occlusion of the cavernous sinus and the bilateral fistula by detachable platinum coils was performed on the patient. The ideal treatment for a direct Carotid cavernous fistula is the exclusion of the fistula from the blood circulation, preserving the system of the carotid artery supply of blood to brain. This is achieved by endovascular treatment (neuro interventional methods) in the Cath lab. A catheter is passed through an artery in the groin up into the carotid artery (artery in neck). By carefully placing the catheter tip inside the fistula (the communicating segment between artery and vein) platinum coils are released into the fistula. These platinum coils are specially prepared to induce clotting of blood in the fistula segment which is supposed to be blocked and can be left in place permanently in the fistula. The shape of these platinum coils are prefixed and size of the coils may range from less than one hair’s width to twice the size of a human hair. Retaining the flow of blood to brain while blocking the flow through the abnormal channel (fistula) is the real challenge in this case, especially when the surgeon needs to do it on both right and left sides in the same patient.”
