Pulsating Exophthalmos Definition

Acute exophthalmos with palpable and audible pulsations synchronous with the pulse in the presence of a cavernous sinus fistula or arteriovenous aneurysm.

Etiology: An abnormal communication between the cavernous sinus and the internal carotid artery (a direct shunt) or its branches (indirect shunt) results in distention of the orbital venous network. Eighty per cent of all cases are attributable to trauma; less frequently the disorder is due to syphilis or arteriosclerosis.

Symptoms: Patients report an unpleasant sound in the head that is reminiscent of a machine and synchronous with their pulse.

Diagnostic considerations: The increased venous pressure leads to dilation of the episcleral and conjunctival vessels (Fig. 15.7), retinal signs of venous stasis with bleeding, exudation, and papilledema. Intraocular pressure is also increased. The increased pressure in the cavernous sinus can also result in oculomotor and abducent nerve palsy.

H Sounds near the direct fistula are clearly audible with a stethoscope.

Fig. 15.7 The episcleral and conjunctival vessels are significantly dilated and describe tortuous corkscrew courses.

— Fistula between the carotid artery and cavernous sinus.

— Fistula between the carotid artery and cavernous sinus.

Fig. 15.7 The episcleral and conjunctival vessels are significantly dilated and describe tortuous corkscrew courses.

Doppler ultrasound studies can confirm a clinical suspicion. However, only angiography can determine the exact location of the shunt.

Treatment: Selective embolization may be performed in cooperation with a neuroradiologist once the shunt has been located.

H Small shunts may close spontaneously in response to pressure fluctuations such as can occur in air travel.

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