The association of carotid cavernous fistula with Graves’ ophthalmopathy
A 72-year-old woman who was diagnosed with Graves’ disease and mild bilateral ophthalmopathy 1 year ago and treated with propylthiouracil was admitted to our hospital because of grittiness, eye discomfort, proptosis, and swelling of both eyes; exophthalmos, eye pain, visual disturbance, conjunctive congestion and chemosis in the right eye []. She had progressive visual disturbance on the right eye. The patient had undergone corticosteroid treatment with 16 mg/day methylprednisolone for 1 month and than 30 mg/day deflazacort for 2 months for the opthalmopathy. Her laboratory results were as follows fT4: 1.19 ng/dl (0.7-1.7), TSH: 2.24 mU/l (0.4-4), TSH receptor antibodies and thyroid peroxidase antibodies were positive. The orbital MRI images revealed exophtalmos in the right eye, an enlargement in the right extraocular muscle and in the right retro-orbital fatty tissue. The right optic nerve diameter was less than the left one. The patient's ophthalmopathy was diagnosed as asymmetrical thyroid ophthalmopathy but also, carotico-cavernous fistula was considered in differential diagnosis. A cerebral angiography was performed and a dural carotid cavernous fistula was observed on the right side []. This dural CCF was draining through the right superior opthalmic vein as well as the left superior opthalmic vein via posterior intercavernous sinus connection. Endovascular treatment of the right-sided superior opthalmic vein drainage was accomplished by closing the right cavernous sinus with platinum coils. However, although the small left-sided drainage was persisted since then, there was no left-sided superior opthalmic vein drainage and therefore right-sided drainage was decided to be left untreated. After 2 months, the symptoms regressed, a full vision of right eye was obtained and radiological improvement was noted [].