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Iatrogenic Carotid Cavernous Sinus Syndrome
MICHAEL G. HUMMER, M.D., AND THOMAS J. CARLOW,
A hemodlalysls shunt site, subclavian artery
to internal jugular rein, resulted in a "pseudo"
cavernous sinus syndrome. Recognition of this rare iatrogenic complication may assist in selecting other shunt
Stroke, Vol 12, No 5, 1981
THE FULLY DEVELOPED clinical picture of a carotid cavernous sinus fistula (CCF) is not a diagnostic dilemma. These vascular malformations commonly are either traumatic or spontaneous.1 This report is of a iatrogenic instance with clinical signs and symptoms of a carotid cavernous sinus syndrome following a subclavian artery to internal jugular vein shunt.
(fig. 1). An ocular bruit was not heard and both globes were neither tender nor pulsating (utilizing a Schi^tz tonometer). Visual acuity was correctable to 20/25 on the right and 20/20 on the left. Pupils were 4 mm bilaterally and equally responsive to light and ac- comodation. Applanation tonometry readings were 12 mm Hg on the right and 10 mm Hg on the left. Vergence, version and duction extraocular movements were normal. Fundus examination showed mild dila- tion of the left retinal veins.
A 62-year-old right-handed man had received 6 years of hemodialysis treatment for membranous glomerulonephritis. Multiple episodes of thrombo- phlebitis eventually consumed all common sites for peripheral hemodialysis fistulas. Renal transplanta- tion was unsuccessful. Since all peripheral shunt sites had failed, a left subclavian artery to left internal jugular vein shunt was selected. Within three weeks after the anastomosis, he experienced holocephalic headaches and mild generalized weakness, worse on his right side. A slow but progressive reddening of his left eye was noted. He denied diplopia, subjective bruit, pain and decreased visual acuity.
Neurological examination documented a mild but distinct pronation drift of the right arm without ten- don reflex asymmetry. Ophthalmologic examination revealed a marked dilation and arterialization of the left conjunctival vessels and 2 mm of left proptosis
From the Veterans Administration Medical Center, Department of Neurology, University of New Mexico School of Medicine,
Albuquerque, NM 87108. Reprints: Dr. Carlow,
VA Medical Center,
mology Laboratory, Bldg. 13, 2100 Ridgecrest SE, Albuquerque, NM 87108.
Abnormal laboratory studies included: BUN 64 mg/dl, creatinine 8.5 mg/dl, total protein 5.4 gm/dl, albumin 2.9 gm/dl, prothrombin time 25.7 seconds (control 11.8) and partial thromboplastin time 67.3 seconds (normal less than 40 seconds). Urinalysis revealed a specific gravity of 1.017, 2+ glucose, 3+ protein, 2-6 wbc/hpf, and 1-3 casts/lpf.
An EEG showed slowing and decreased amplitude over the left frontal area. The CT scan suggested a left frontal chronic subdural hematoma. Within a week after the subdural was evacuated the right sided weakness and the EEG improved markedly.
A left carotid arteriogram, after removal of the sub- dural hematoma, showed slow arterial filling of the left cerebral hemisphere with all venous drainage from that side via the right transverse sinus and right inter- nal jugular vein. A left subclavian arteriogram documented left cavernous sinus arterialization from retrograde flow in the left internal jugular vein, transverse sinus and petrosal sinus. Blood flow was from the shunt into the left carotid cavernous sinus (fig. 2). Since venous drainage from the left cerebral hemisphere occurred through the right internal jugular vein, the left internal jugular vein was ligated above the fistula. Two months later the patient was symptom