The most common symptoms were diplopia 61%, headache 53%, and facial or orbital pain 32%. To describe the etiology and clinical presentaton of carotidcavernous fistulas. Carotid cavernous fistulas ccfs are an abnormal shunt from the carotid. When a direct ccf is confirmed, firstline treatment is endovascular intervention, which may be accomplished using detachable balloons, coils. Search results carotidcavernous fistula pubmed health. Most type a carotid cavernous fistulas are high flow and traumatic in origin. These fistulas usually result from some injury, like an automobile mishap or mugging. Because of the varied and important structures within the cavernous sinus, serious pathophysiologc changes may result from trauma andor infection of this region. Report of 32 surgically treated cases and suggestions for definitive operation. Carotid cavernous fistulas ccfs, spontaneous or traumatic, is an abnormal. Pilojection for carotid aneurysm in the cavernous sinus.
Endoarterial and transvenous approaches through the jugular, inferior petrosal. Carotidcavernous fistula an overview sciencedirect topics. As arterial blood under high pressure enters the cavernous sinus, the normal venous return to the cavernous sinus. This separates the blood flow of the carotid arteries from that of the veins. Adenomas are characterized as invasive or agressive. J, a healthy 42yearold male, suffered a serious head injury due to an accidental fall from a rooftop in december 2003. Ccfs can be classified by anatomy direct or dural, etiology traumatic or sponta. Carotidcavernous fistula and carotid artery aneurysm sonoworld. This was reported by browder,1 in 1937, in a case of fistula of the cavernous sinus. The clinical presentation of ccfs, which is a direct consequence of elevation in intracavernous pressure and revised flow patterns, mostly comprises of ocular findings. Endosaccular treatment of 1 cavernous carotid artery. Meaning of carotid cavernous sinus fistula medical term.
Between november 1991 and december 2005, a total of 141 patients 112 female with dural carotidcavernous sinus fistula underwent 161 transvenous treatment sessions. A carotidcavernous sinus fistula is an abnormal connection that forms between a carotid artery in your neck and the network of veins at the back of your eye. Key woros 9 carotidcavernous fistula 9 dural cavernous sinus fistula intracavernous carotid artery 9 cavernous sinus 9 angiography 9 arterial embolization 9 detachable balloon catheter c arotid cavernous sinus fistulas ccsfs are abnormal communications between the carotid artery and the cavernous sinus. Direct carotidcavernous fistula resulting from direct communication of the cavernous carotid artery and the cavernous sinus with resultant high velocity of blood flow most often results from trauma or from rupture of a preexisting aneurysm of the cavernous carotid artery. Three cases of carotid artery fistulas have been reported, including two direct carotid cavernous fistulas and one external carotid artery fistula. These aneurysms usually cause neurological symptoms due to gradual expansion without rupture. Pdf carotid cavernous fistulas ccfs are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. Korkmazer b, kocak b, tureci e, islak c, kocer n, kizilkilic o. Pdf carotid cavernous fistula ccf is an abnormal communication between the cavernous sinus and the carotid arterial system. Four cases in which the diagnosis of carotid cavernous fistula was made by using ct angiography are illustrated. A ccf can be due to a direct connection between the cavernous segment of. The diagnosis was confirmed by digital subtraction angiography in all four instances.
Interestingly, it has been reported that 20%60% of. Direct carotid cavernous fistula after trigeminal balloon. Development of carotid cavernous fistula after traumatic. The initial portion ofthe sshaped cavernous carotid artery ascends toward the posterior clinoid process forming, then. The main symptom is diplopia, caused by compression injury of the oculomotor nerves.
A retrospective analysis of 38 carotid cavernous fistula patients. Any information contained in this pdf file is automatically generated from digital material submitted. Patients may have double vision as the nerves that control the eye are affected or vision. A carotid cavernous fistula is an abnormal communication between the carotid arterial system and the cavernous sinus. Direct carotid cavernous fistulas are highflow shunts with a direct connection between the internal carotid artery and the. When ccas rupture, they generally produce a carotidcavernous sinus fistula, the treatment of which is relatively straightforward, with little or no mortality and little morbidity using current endovascular techniques. Traumatic carotid cavernous fistula is often a highflow fisfigure 2. Recurrent carotid cavernous fistula originating from a. Carotid cavernous fistula carotid cavernous fistulas are a specific type of abnormal connection of the arteries directly into the venous system. The goals of treatment are to eliminate the fistula and. Treating a carotid cavernous fistula with embolization involves placing small platinum coils where the abnormal connection is. Carotid cavernous fistula due to a ruptured intracavernous. Carotidcavernous fistula definition of carotidcavernous. Original article a retrospective analysis of 38 carotid.
Get a printable copy pdf file of the complete article 2. The ocular findings in carotid cavernous fistula in a series of 17 cases. Carotidcavernous fistulas ccfs are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. Developmental spine disease 1normal embryological development of spine. Report of 32 surgically treated cases and suggestions for.
Carotid cavernous sinus fistulas and venous thrombosis 141 radiographic signs of cavernous sinus thrombosis were found in eight consecutive patients with an angiographic diagnosis of carotid cavernous sinus fistula. May 24, 2019 carotid cavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. Doctor answers on symptoms, diagnosis, treatment, and more. Type a are direct high flow shunts between the internal carotid artery and the cavernous sinus. The carotid artery, the main supply to the head, can establish a direct connection to the veins in the cavernous sinus lead to pronounced elevation of pressure in the veins which will dilate throughout the front of the head and can. The anatomy of the lesion can vary, ranging from fistulas connecting the internal carotid artery or external carotid artery to the cs. Classification and treatment of spontaneous carotid cavernous.
Patient with right eye redness and swelling carotidcavernous fistula embolization division of interventional neuroradiology presents a patient case treated by the team members of the division and physicians and staff of the ucla comprehensive stroke center signal in her cavernous sinus, gary duckwiler, md director and professor. Spontaneous direct carotidcavernous fistula in ehlers. The woman underwent endovascular treatment with coiling of the cavernous sinus in combination with application of the onyx embolic agent in the fistula. This results in highpressure arterial blood entering the lowpressure venous structure. They can be classified as direct or indirect which are separate conditions with different etiologies.
A carotid cavernous fistula ccf is an abnormal communication between. B, left internal carotid angiogram, lateral view, showing a dural arteriovenous fistula at the posterior cavernous sinus. Transcavernous repair of carotid cavernous fistula in. What is a carotid cavernous fistula doctor answers. Carotid cavernous sinus fistulae are rare, but serious, vascular anomalies which may develop following traumatic injury to the skull base. Lesions affecting the cavernous sinus may affect isolated nerves or all the nerves traversing through it.
Confirmatory magnetic resonance imaging and angiography demonstrated a right carotid cavernous fistula ccf fig. Marginal sinus fistulas msfs are uncommon vascular anomalies. J was comatose for 4 days and sustained multiple fractures of the. Internal carotid artery injury may also occur after misguided needle placement, particularly far posteriorly or medially, resulting in carotid cavernous fistula. If detected early, the condition can be easily treated with an endoscopic procedure, but if left untreated it can. A carotidcavernous fistula ccf is an abnormal communication between branches of the carotid artery and the cavernous sinus. A caroticocavernous fistula ccf may be due to either a direct connection between the cavernous ica and the cavernous sinus and present acutely, or due to an indirect connection via small branches of the ica, eca, or as in this case both. Among all types of carotid cavernous fistulas ccfs, especially direct ccf by carotid cavernous aneurysm cca rupture sometimes requires urgent treatment due to acute cranial nerve and visual impairment, epistaxis, and, most devastatingly, subarachnoid hemorrhage. Indirect fistulas are due to communication by multiple branches between the internal andor external carotid arteries and the cavernous sinus. The treatment of a carotid cavernous fistula ccf depends on the severity of the clinical symptoms, its angiographic characteristics, and the risk it presents for intracranial hemorrhage. Long term visual and neurological prognosis in patients.
A cavernous carotid fistula ccf is an abnormal communication between the carotid artery and the cavernous sinus cs. A week later, he presented with headache and the classic triad of ccf. Similar results for manual compression in the treatment of indirect ccfs have been reported by other groups. The characteristic clinical features seen in patients with ccfs are. Carotid cavernous fistula may result from the down fracture of the maxilla or the pterygoid osteotomy, thus injuring the internal carotid artery. Carotid cavernous fistula ccf is an abnormal communication between the cavernous sinus and the carotid arterial system. Based on this classification, our case belongs to type a ii. The direct type mainly results from trauma or rupture of a cavernous internal carotid artery ica aneurysm. The arab board of health specializations radiology and. Carotidcavernous sinus fistula definition of carotid. Cavernouscarotid fistula presenting with intracerebral.
Treatment of carotid cavernous fistulas request pdf. Itsentrance into the cavernous sinus isfrequently demarcated byabandlike impression ofthe dura. As arterial blood under high pressure enters the cavernous sinus, the normal venous return to the cavernous sinus is impeded and this causes engorgement of the. The most frequent are type c, with meningeal branches of the external carotid forming the fistula 3. Direct carotid cavernous fistulas are highflow shunts with a direct connection between the internal carotid artery and the cavernous sinus.
Carotidcavernous fistula knowledge for medical students. For this reason it is essential to remember the anatomy of these structures as well as their. Endovascular strategies for carotid cavernous and intracerebral dural arteriovenous fistulas. Endovascular treatment strategy for direct carotid cavernous fistulas resulting from rupture of intracavernous carotid aneurysms.
The cavernous sinus is the only site in the human body where an artery passes completely through a venous structure. Within the cavernous sinus, the internal carotid artery issituated between layers of the dura mater forming the sinus. Carotid cavernous sinus fistula and aneurysmal rupture associated with fibromuscular dysplasia. The difference in the blood pressure between the arteries and the veins behind the eye leads to a buildup of blood in a persons eye. Patient with right eye redness and swelling carotidcavernous. A carotid cavernous sinus fistula is an abnormal connection that forms between a carotid artery in your neck and the network of veins at the back of your eye. The pituitary gland lies between the two paired cavernous. If they do rupture they most often lead to a ccf instead of bleeding into the subarachnoid space. Carotid cavernous fistulas are anomalous communications between the arteries from the carotid system with the cavernous sinus. As a result, the blood can drain properly from the eyes. Marginal sinus arteriovenous fistulas mimicking carotid. Patients present with proptosis, ecchymosis redness, and pain around the affected eye.
Any information contained in this pdf file is automatically generated from digital material. The cause of fistula is etiologically spontaneous and mostly traumatic 75%. This article is from march 2008 and may contain outdated material. Campbell, ddst the cavernous sinuses and associated structures comprise a unique and intricate physioanatomic unit. Carotid cavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. Oka y, sadamoto k, tagawa m, kumon y, sakaki s, fujita m. Occasionally, the dominant venous drainage is forced retrograde up the inferior petrosal sinus and into the cavernous sinus, causing chemosis, proptosis, and ocular hypertension, mimicking a carotid cavernous fistula. A carotid cavernous fistula ccf can be classified into direct or indirect types, or a combination of both. A ptient is described with a ruptured intracavernous aneurysm causing a ccf resulting in acute onset of. Traumatic carotid cavernous fistula accompanying basilar skull fracture.
Carotid cavernous fistula associated with persistent primitive trigeminal artery. Fifteen patients 48% were diagnosed after they developed cranial nerve pareses, four % after they developed carotid cavernous sinus fistulas ccfs, and 12 39% by neuroimaging studies done for unrelated symptoms. Carotid cavernous sinus fistulas ccfs are abnormal communications between the carotid arterial system and the cavernous sinus. A carotid cavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. Anatomy and differential diagnosis poster no c0517. Transvenous embolization of carotidcavernous sinus fistula associated with a primitive trigeminal arterycase report. A, left external carotid angiogram, anteriorposterior view, showing shunt flow into the left cavernous sinus. Urgent treatment of severe symptomatic direct carotid.
Ccf is an abnormal communication between carotid arterial system internal carotid artery ica or external carotid artery eca and cavernous sinus cs fig. If the internal carotid artery ruptures within the cavernous sinus, an arteriovenous fistula is created more specifically, a carotid cavernous fistula. The treatment modalities include conservative management, which consists of medical management and manual compression therapy. For low flow fistulas, conservative therapy is the least.
Carotid cavernous sinus fistula the first case of a pulsating exophthalmos occurring only on the side opposite a carotid cavernous fistula was reported by pincus r in 1907. The purpose of this study was to evaluate the singlecentre experience with transvenous coil treatment of dural carotidcavernous sinus fistulas. Eleven days after the accident the right eye was blind and showed ptosis, hematoma of the lids, lateral rectus paralysis, other extraocular muscle weaknesses. Percutaneous ganglyolysis treatment of trigeminal neuralgia is rarely associated with vascular complications, such as hematoma, subarachnoid hemorrhage, and stroke. Increased pressure within the cs seems to be the mainstay of pathophysiology, although arterial steal and increased flow plays an important role. The potentially sightrobbing vascular abnormality known as the carotid cavernous sinus fistula ccf can masquerade as conjunctivitis or other common ocular conditions, which diminishes the chance for a speedy diagnosis. Carotidcavernous sinus fistulas and venous thrombosis. Looking for online definition of carotid cavernous sinus fistula in the medical dictionary. However, some are iatrogenic, happening during a neurosurgical or interventional neuroradiological procedure. A ccf can be due to a direct connection between the cavernous segment of the internal carotid artery and the cavernous sinus, or a communication between the cavernous sinus, and one or more meningeal branches of the internal carotid artery, external carotid artery or both. Type c ccfs are dural shunts between external carotid meningeal branches and the cavernous sinus fig.
Carotid cavernous fistula joseph niamtu, iii, dds, and robert l. A carotid cavernous fistula ccf is an abnormal passage between the venous cavernous sinus and the internal carotid artery. Drainage is toward the ips and the contralateral ips through the intercavernous sinus. Endovascular treatment of carotid cavernous sinus fistula. Ccfs are classified into two main types based on their pathophysiology, direct type a and indirect type bd 1, 2, as shown in figure 1. Carotid cavernous fistula is an abnormal arteriovenous communication between the carotid artery or its branches and the cavernous sinus. Visual impairment in high flow and low flow carotid cavernous fistula. Carotid cavernous fistulas cc fistulas trauma rupture of cavernous sinus aneurysm. We present one case of direct carotid cavernous fistula, which is the only reported case of this complication associated with microcompression gangliolysis. Classification and treatment of spontaneous carotid. Type a carotid cavernous fistulas secondary to the rupture of an aneurysm of the cavernous segment of the internal carotid artery are much less common, accounting for no more than 20% of reported cases 2, 3.
Carotid cavernous fistulas ccfs are a rare but potentially devastating cause of orbital symptoms, visual loss, and periocular disfigurement. Case report comprehensive endovascular treatments of. Manual compression of the ipsilateral carotid artery and jugular vein can help. Hypoxic ocular sequelae of carotidcavernous fistulae. The conventional cerebral panangiography confirmed the diagnosis a direct carotid cavernous fistula ccf, with no evidence of ruptured aneurysm. Lateral image of the left internal ca rotid artery showing the balloon placed at the suspicious rupture of the pos.
Once routinely treated with open surgical procedures, including carotid. Outcome of carotidcavernous fistula embolization with. Thus, experience showed that ligation of the carotid. In any patient presenting with a spontaneous direct carotid cavernous fistula, family history and clinical examination should be targeted toward a diagnosis of ehlersdanlos syndrome type iv because of risks attendant to. The fistula was successfully treated angiographically. Fractures or the shearing forces of severe head trauma. Signs and symptoms are related to the compression of structures within the cavernous sinus, including the. A carotid cavernous fistula is an abnormal communication between a carotid artery and the cavernous sinus. A 31yearold man sustained trauma to the right side of his head. Spontaneous direct carotidcavernous fistula in an elderly. As surgical treatment of these aneurysms can be technically challenging, endovascular management has emerged as the preferred treatment modality. Caroticocavernous fistula radiology reference article. Intracavernous carotid artery aneurysms causing a carotid cavernous fistula ccf are rare.
Dural venous fistula 2avm 3 cavernous angioma 4spinal cord infarct i. Transarterial embolization surgery was performed with complete closure of the ccf. Type b ccfs are dural shunts between meningeal branches of the cavernous ica arising from the meningohypophyseal or ilt trunks and the cavernous sinus fig. A carotidcavernous fistula is an abnormal communication between a carotid artery and the cavernous sinus. It constitutes, in this way, a pathology with an underlying structural alteration. Carotid cavernous fistula patients typically present with proptosis, elevated intraocular pressure, prominent tortuous conjunctival vessels, and sometimes headache. During this time, the authors treated 48 patients for dural arteriovenous fistulae of the cavernous sinus. Carotid cavernous fistula after percutaneous balloon.
The preferred treatment for traumatic carotid cavernous fistula tccf is to embolize the fistula with detachable balloon. The characteristic clinical features seen in patients with ccfs are the sequelae of hemodynamic dysfunction within the cavernous sinus. A carotidcavernous fistula is a vascular disorder in the cavernous sinus region of the skull. Carotid cavernous fistula statpearls ncbi bookshelf.
These lesions may be classified based on the following. The etiology, classification, clinical presentation, complications, and intravascular routes to image and treat carotidcavernous fistulas percutaneously are described. Long term visual and neurological prognosis in patients with. The preferred treatment for traumatic carotid cavernous fistula tccf is to. To our knowledge, this is the first report of the ct angiographic appearance of carotid cavernous fistulas.
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