Complexity in the diagnosis of endocrine ophthalmopathy with a carotid-cavernous fistula. A clinical case

Introduction. Clinical cases featuring a combination of endocrine ophthalmopathy with a carotid-cavernous fistula are scarce, with only four cases documented in the literature, thus posing a diagnostic challenge due to overlapping clinical symptoms. A carotid-cavernous fistula with high blood flow typically presents a clear clinical picture. However, low-flow variants are challenging to timely diagnose. A history of head trauma can be an essential diagnostic clue, as carotid-cavernous anastomosis develops in 75% of cases post-trauma and in 25% spontaneously. Bilateral carotid-cavernous fistulas are particularly rare.

Purpose: to present the clinical features and outcomes of bilateral endocrine ophthalmopathy associated with a non-traumatic carotid-cavernous fistula, based on the prospective observation of a patient treated in various city healthcare hospitals during 2021–2022.

Case description. The patient first visited the ophthalmologist in October 2021, presenting with bilateral exophthalmos, edema, and eye redness. A positive test for antibodies to thyroid-stimulating hormone and enlargement of the eye muscles, confirmed by orbital ultrasound, led to a diagnosis of “Endocrine Ophthalmopathy”. The patient’s condition was managed jointly by an endocrinologist and an ophthalmologist. Over two months, a worsening of ocular symptoms was observed, prompting a neurosurgical consultation. Cerebral angiography conducted in a hospital setting confirmed a carotid-cavernous fistula. An endovascular procedure was performed five months after the initial ocular symptoms appeared to separate the carotid-cavernous anastomosis on the right using a non-adhesive composition. Ocular symptoms resolved within 2–3 weeks post-surgery.

Conclusions. Clinical manifestations of carotid-cavernous fistulas can resemble those of endocrine ophthalmopathy. The absence of a traumatic head injury history, complaints of unilateral head noise synchronous with the pulse, and the bilateral nature of the symptoms complicated the diagnosis of this neurosurgical pathology in a patient with endocrine ophthalmopathy. It is crucial to include both conditions in the differential diagnosis and to employ a multidisciplinary approach for effective management.

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