What is Carotid-cavernous Anastomosis in Children?
Carotid-cavernous anastomosis is a pathological connection of the internal carotid artery and the cavernous sinus inside the cranial cavity, the cause of which is most often a craniocerebral injury, in more rare cases – an infectious lesion of the eye and anomalies of the vessels.
With normal development, arterial blood enriched with oxygen flows through the internal carotid artery. The artery feeds them and other nutrients to the brain – more precisely, most of it. The cavernous sinus is an extension of the intracranial vein. But his blood departs from the brain (including from its membranes), as well as from the eyes and contents of the orbit.
It is very easy to damage the wall of the internal carotid artery in its cavernous part, as it is fragile and very thin there. If damage has occurred, the blood stream under pressure flows into the cavernous sinus, where the blood is mixed with venous. As a result, the pressure in the cavernous sinus increases and the drainage function of the vein is disrupted. Also, venous blood stagnates in the brain and orbit.
There is a significant increase and expansion of the sinus, which because of this puts pressure on the cranial nerves that pass through it: block, oculomotor, maxillary, orbital, abducent.
Causes of Carotid-cavernous Anastomosis in Children
Carotid-cavernous anastomosis in children can be caused by various reasons. For example, 75% of cases are skull injuries that occurred for various reasons. Congenital pathologies, atherosclerotic changes in the wall of the carotid artery (if the child has hypertension), etc. can also be the fault.
Pathogenesis during Carotid-cavernous Anastomosis in Children
An anastomosis is formed between the internal carotid artery and the cavernous sinus (roughly speaking – the connection). The pressure in the cavernous sinus becomes much higher due to the reflux of blood from the artery. This disrupts the outflow of venous blood, which passes through the superior orbital vein.
Symptoms of Carotid-cavernous Anastomosis in Children
One-sided exophthalmos occurs. This is manifested in the protrusion of one of the eyes (depending on the side of the lesion). The ripple of the eyeball can be either felt (to the touch) or visible. At the beginning of the disease, the eyeball can be returned to its place, but as soon as sclerotic processes develop in the tissues of the orbit, it is already difficult to return the apple to the anatomically correct place.
Vision “falls” in about ½ sick children. When the eyelids are closed, a blowing noise appears over the eye. Noise in the periorbital region (around the eye) is also possible. The noise disappears when the carotid artery is squeezed on the neck.
Symptoms such as expansion and tortuosity of the episcleral veins are characteristic, resulting in red chemosis. Most patients have increased intraocular pressure. There may also be symptoms such as dilated veins of the face, headache, nausea and even vomiting, a sharp noise in the head, loss of consciousness.
Diagnosis of Carotid-cavernous Anastomosis in Children
The doctor collects complaints and makes a medical history. It is important how long ago the child’s complaints about the blowing noise in the head, headache, eye pulsation appeared. Parents should indicate whether the child had a head injury before the above symptoms appeared. It is especially important to report a front injury – the child is hit in the face or hit on a glass or seat in a car accident.
Neurological examination is necessary for carotid-cavernous anastomosis in children. Doctors are looking for signs of neurological pathology, which can be manifested in a decrease in the pain threshold on the face and strabismus. Doctors also examine the child for signs of traumatic brain injury – hemorrhages around the eyes, bruises and bruises on the soft tissues of the head, strabismus, etc.
The fundus is examined for signs of edema of the optic disc. Sometimes skull x-ray is prescribed to find the location of the fracture. According to indications, cerebral angiography is prescribed. It is carried out as follows: a special contrast is introduced into the bloodstream of the child, which is visible on the X-ray images (a series of them is carried out to see the carotid-cavernous anastomosis, in which the contrast fell).
Among the diagnostic methods for carotid-cavernous anastomosis – CT and MRI – computed tomography and magnetic resonance imaging of the brain. Your child may also need a consultation with a neurosurgeon.
Treatment of Carotid-cavernous Anastomosis in Children
This disease is treated surgically. Mainly endovasal surgery is used. A catheter is inserted into the internal carotid artery, at the end of which there is a discarded balloon. A balloon with a blood flow is sent to the affected segment of the carotid artery and placed in a sinocarotid anastomosis. The balloon is inflated with air and temporarily “clogged” with it anastomosis. If blood circulation in the internal carotid artery is not disturbed, the balloon is filled with quick-hardening silicone with tantalum powder and separated from the catheter, and the catheter itself is removed.
This method allows you to save the child’s vision and save the message of the arterial circle of the brain with the system of the external carotid artery through the orbital artery; venous and arterial blood are also shared. As a result of the operation, complications may arise, for example, a balloon dropped from a catheter may move into the cavernous sinus, the balloon may burst, etc.
Surgical interventions such as inserting a piece of muscle into the carotid-cavernous anastomosis to block it are also possible; Ligation of the superior orbital vein deep in the orbit according to Golovin; ligation of the internal carotid artery on the neck, intracranial clipping of it and the orbital artery. These operations are combined if necessary.
In less than 18% of children with a diagnosis of fistula, the fistula may spontaneously close.
Forecast
If the treatment is done on time and correctly, the symptoms disappear gradually. If the anastomosis has existed for a long time, the tissues of the orbit can become denser.
Prevention of Carotid-cavernous Anastomosis in Children
Prevention measures are not developed. Children with traumatic brain injury should undergo a thorough examination, especially if there are signs of fracture of the base of the skull. Timely diagnosis ensures no complications.