Gudrun Brismar

Spontaneous Carotid-Cavernous Fistulas Phlebographic Appearance and Relation to Thrombosis

Six consecutive cases with spontaneous carotid-cavernous fistulas were examined with orbital phlebography and bilateral carotid angiography. One of the fistulas was fed only by one internal carotid artery, 1 only by the accessory meningeal branch of the maxillary artery, while 4 were supplied by external as well as internal carotid arteries. The findings at phlebography seem to be characteristic. Thrombosis was demonstrated in all 6 cases. Different mechanisms for the genesis of thrombosis in association with carotid-cavernous fistulas are proposed. Alternative therapy methods are discussed.

Unilateral endocrine exophthalmos. Diagnostic problems in association with computed tomography

SummarySwollen orbital extraocular muscles may mimic an orbital apex tumor on computed tomography. In five of our patients, in spite of highly suggestive findings on CT scanning, indicating the presence of an orbital apex lesion, the correct diagnosis proved to be endocrine exophthalmos. The value of complementary CT projections and of orbital ultrasonography to assist in the differential diagnosis is discussed, and the additional contribution of orbital phlebography for the confirmation of lesions in the orbital apex is emphasized.

Spontaneous carotid-cavernous fistulas. Clinical symptomatology.

The symptomatology in six cases with spontaneous carotid‐cavernous fistulas is discussed. All six patients presented with exophthalmos, dilated veins, pain and restriction of ocular movements. In four patients a bruit was found objectively as well as subjectively, four patients exhibited an increase of the intraocular pressure and in three cases vision was impaired. Of special interest is the finding that discrete symptoms such as venous congestion and slight pain appeared early in the course of the disease in all patients, and that in some of the patients an increase in intraocular pressure as well as disturbances in ocular motility were diagnosed long before the appearance of the exophthalmos.

Thrombosis of the intraorbital veins and cavernous sinus.

Eight cases with phlebographic appearances consistent with aseptic thrombosis of the cavernous sinus or of the posterior part of the superior ophthalmic vein are presented. The clinical course is briefly described and the phlebographic findings and possible differential diagnoses discussed. Even if recent methods may obviate the need for phlebography in the demonstration of orbital tumors in certain cases, the possibility of intraorbital or cavernous sinus thrombosis constitutes an important indication for phlebography.

Complications of orbital and skull base phlebography.

Two complications, one in association with frontal vein phlebography and one in association with inferior petrosal sinus phlebography, are presented. Possible mechanisms for complications are discussed. It is concluded that a significant risk exists in association with inferior petrosal sinus phlebography, particularly in association with vascular disorders of the skull base, while the risk in association with orbital phlebography after frontal vein puncture is minimal if compression of the jugular veins is omitted.

Bilateral exudative retinal detachment in pregnancy

Abstract A case of bilateral exudative retinal detachment associated with otherwise normal pregnancy is presented. Similar cases, but associated with toxemia of pregnancy from the literature are discussed. As far as we know, this is first reported case where bilateral exudative retinal detachment presented in a normal pregnancy and the re‐attachment started promptly after a normal, spontaneous delivery. The re‐attachment was complete, and the visual acuity after one year was 20/20 o.u. This case supports earlier theories that hypertension is not the only cause of exudative retinal detachment during pregnancy.

Orbital phlebography. Technique and clinical applications.

The technique for orbital phlebography is described and the phlebographic anatomy of the orbit and the skull base presented. The possibilities and limitations of phlebography in the diagnosis of different intraorbital and ophthalmoneurological disorders is discussed and illustrated out of personal experiences from 200 cases.

Superior ophthalmic vein at computed tomography.

The superior ophthalmic vein is the main intraorbital vein and is connected by abundant collaterals, directly or indirectly, with all other intraorbital veins. It is always filled at orbital phlebography in normal cases, provided an adequate phlebographic technique is used (BRISMAR 1974) and is also usually demonstrable following selective injection into the maxillary artery. Occasionally the superior ophthalmic vein is filled following selective injection into the internal carotid artery; the diagnostic implications of such a finding have been the subject of recent reports by HACKER & PORRERO (1969) and TORNOW & PISCOL (1971). The superior ophthalmic vein is formed behind the pulley of the superior oblique muscle by the union of tributaries from the supraorbital and angular veins. Initially it courses posteriorly but soon turns laterally to enter the muscular cone, crossing under the superior rectus muscle (anterior segment). It appears again on the lateral side of this muscle and then runs postero-medially following the lateral border of the superior rectus muscle (middle segment). The vein then descends to leave the orbit through the superior orbital fissure (posterior segment) and empties into the cavernous sinus.

Aseptic Venous Thrombosis or Tolosa-Hunt Syndrome: Discussion of Diagnostic Criteria with Reference to 12 Personal Cases

Painful ophthalmoplegia, i.e. affection of the ocular motor nerves as well as the trigeminal nerve, may be caused by a variety of lesions affecting the superior orbital fissure or the cavernous sinus. It has thus been described in association with neoplasms (especially nasopharyngeal carcinoma growing along the skull base), intracavernous carotid aneurysms, carotid cavernous fistulas and inflammatory conditions (specific, such as tuberculosis and syphilis, as well as unspecific). Sometimes, however, no underlying disorder is found in spite of extensive evaluations. Hunt et al. (1961) noticed that such cases often responded dramatically to steroid therapy, and suggested that cases exhibiting such a response might constitute a diagnostic entity, probably caused by some low-grade nonspecific inflammatory condition. Several similar cases have since been presented by different authors and the condition is now known as the Tolosa-Hunt syndrome. In a few cases surgery has been performed, disclosing granulomatous changes in the region of the superior orbital fissure — cavernous sinus (Tolosa, 1954; Lakke, 1962; Schatz & Farmer, 1972; Levy et al. 1975). Singular cases have been subjected to orbital phlebography demonstrating occlusion of the superior ophthalmic vein (Sondheimer & Knapp, 1970; Milstein & Morretin, 1971; Hunt, 1976).