Painful oculomotor palsy caused by posterior-draining dural carotid cavernous fistulas
M. D. Acierno, J. D. Trobe, W. T. Cornblath and S. S. Gebarski
W. K. Kellogg Eye Center, Department of Ophthalmology, USA.
BACKGROUND: Carotid cavernous fistulas cause conjunctival hyperemia and
orbital soft-tissue swelling because of increased flow directed anteriorly
in ophthalmic veins. Less well recognized is that when fistular flow is
directed posteriorly, these congestive features will be absent and the
diagnosis of the "white-eyed shunt" will be missed unless angiography is
performed. METHODS: Two patients who had oculomotor nerve palsies caused by
posteriorly draining dural carotid cavernous fistulas were studied, and the
28 previously described cases were reviewed. RESULTS: One patient had a
chronic painful palsy of the sixth cranial nerve, and the other, a palsy of
the third cranial nerve. Cerebral angiography disclosed the fistulas. The
clinical and imaging features of these cases conform to those of the 28
previously reported white-eyed shunts. Angiographic features do not explain
why some posterior-draining fistulas cause sixth-nerve palsies and others
cause third- (or rarely, fourth-) nerve palsies. CONCLUSIONS: Dural carotid
cavernous fistulas that drain primarily into the inferior petrosal sinus
may cause painful oculomotor palsies that elude diagnosis because they lack
congestive orbito-ocular features. Treatment by embolization leads to more
rapid resolution of manifestations.
