Images in clinical medicine from the new england journal of medicine carotid cavernous fistula. Dural carotid cavernous fistulas dccfs constitute a rare condition caused by abnormal communications between meningeal branches of the internal or external carotid artery and the cavernous sinus, typically diagnosed in postmenopausal women. Carotid cavernous fistula ccf occurs when an aneurysm of the. Pdf endovascular trapping of direct carotidcavernous. Spontaneous carotidcavernous fistula during pregnancy or in. Longterm outcome after coil embolization of cavernous sinus. A woman with a red eye from a carotidcavernous sinus fistula cmaj. The symptomatology of ccfs is mainly a result of the effects on important neural and vascular structures in the cavernous sinus which include cranial nerves iii, iv, v1, v2, and vi. Complete occlusion of these fistulas with transvenous treatment alone has. Carotid cavernous fistula an overview sciencedirect topics. Traumatic carotid cavernous fistulas ccfs present the clinician with diagnostic and surgical challenges. Initial treatment consisted of conservative debridement.
On the basis of cerebral angiographic findings, both patients were considered to have dural arteriovenous fistulas in the region of the cavernous sinus and both demonstrated spontaneous improvement. Pdf carotid cavernous sinus fistula with non pulsatile. Report of 32 surgically treated cases and suggestions for definitive operation. May 21, 2020 carotid cavernous fistula ccf is defined as abnormal arteriovenous communications between the internal carotid artery or meningeal branches of the external carotid artery and the cavernous sinus 1.
An abnormal connection between the carotid artery in the neck and the cavernous sinus a venous plexus within the skull. He subsequently underwent endovascular embolization treatment. Cavernous sinus enhancement on computed tomography also suggested a retroorbital process. Diagnosis and management of dural carotidcavernous sinus. A patient is presented who developed carotid cavernous sinus fistula 1 year after midface advancement. Carotidcavernous fistulas ccfs are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. Endovascular treatment strategy for direct carotid cavernous fistulas resulting from rupture of intracavernous carotid aneurysms. Diagnosis and management of dural carotid cavernous sinus fistulas. Paper diagnosis and treatment of dural carotidcavernous.
Direct type a fistulas are direct communications between the internal carotid artery ica and the cavernous sinus, usually associated with high flow rates. Cranial magnetic direct carotid cavernous fistulas ccf are characterized resonance imaging mri and magnetic resonance angiog by a direct connection between the internal carotid artery raphy mra were performed in all patients, and 11 ica and the intraluminal space of the cavernous sinus pseudoaneurysms were demonstrated in ten of the 11. If they do rupture they most often lead to a ccf instead of bleeding into the subarachnoid space. In this case report, we describe a rare case of an iatrogenic direct ccf following mechanical thrombectomy mt for acute ischemic stroke. Ct angiogram findings in carotidcavernous fistulas.
Treatment of recurrent carotid cavernous fistula by direct. Feb 23, 2021 pdf carotid cavernous fistula ccf is an abnormal communication between the cavernous sinus and the carotid arterial system. 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 draining veins, manifesting most dramatically as a sudden engorgement and redness of the eye of the same side. Carotidcavernous fistula an overview sciencedirect topics. Classification and treatment of spontaneous carotid. Carotidcavernous fistula presenting with bilateral. Medicine from the new england journal of medicine carotidcavernous sinus fistula. Treatment of direct carotid cavernous fistulas has evolved from surgical. Pdf carotid cavernous fistula ccf fiveslides neurosurgery. Current concepts on carotid arterycavernous sinus fistulas. Carotidcavernous sinus fistula definition of carotid. A ptient is described with a ruptured intracavernous aneurysm causing a ccf resulting in acute onset of.
The ccf is an abnormal arteriovenous connection between the carotid artery and the venous cavernous sinus. A carotidcavernous fistula ccf is an abnormal communication between the. Ruptured cavernous sinus aneurysms causing carotid cavernous fistula. Pdf followup of endovascular treatment of direct carotid. These aneurysms usually cause neurological symptoms due to gradual expansion without rupture. Treatment was by embolization via a transvenous approach through the superior ophthalmic vein sov. Placement of a detachable balloon across the fistula site while preserving the pta proved impossible, and the fistula was treated with microcoils following placement of a microcatheter across the fistula into the cavernous sinus. Spontaneous carotidcavernous fistula during pregnancy or. A perplexing surgical problem published on nov 1959 by journal of neurosurgery publishing group. These require treatment and often are seen with bulging eyes and bruits in the eyes. All patients underwent pre and postcontrastenhanced cta and. Type a fistulas are direct communications between the internal carotid artery ica and the cavernous sinus, usually associated with high flow rates. They can be classified as spontaneous or traumatic.
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. Carotidcavernous sinus fistula following le fort i osteotomy. A carotid cavernous sinus fistula ccf is an arterialvenous fistula between the internal carotid artery and cavernous sinus, and can be classified as either direct or indirect. Marginal sinus arteriovenous fistulas mimicking carotid.
Catheter angiography confirmed a direct carotid cavernous fistula with intra and extracranial venous drainage. Carotid cavernous fistula was confirmed by cerebral angiography, and the clinical symptoms then improved. The symptoms of carotid cavernous fistula of buzzing in the ear, proptosis, and chemosis were. Direct carotid cavernous fistula due to rupture of a cavernous carotid aneurysm embedded within a prolactinoma after cabergoline administration. The authors describe the method and results of treatment of 12 consecutive patients with carotid cavernous sinus fistulas ccfs.
Carotid cavernous sinus fistula ccf is an abnormal connection between the c4 cavernous segment of the internal carotid artery ica, external carotid artery eca, and the cavernous sinus. Pdf endovascular treatment of carotid cavernous fistulas. Aug 04, 2017 a carotidcavernous sinus fistula ccf is an abnormal connection between an artery in your neck and the network of veins at the back of your eye. Isolated contralateral abducens palsy in direct carotid. This atypical clinical presentation may lead to misdiagnosis and inappropriate hazardous treatment of an. Traumatic carotid cavernous fistula tccf is a direct communication between cavernous portion of the internal carotid artery ica and cavernous sinus due to tear in ica. A carotid cavernous fistula ccf is an abnormal communication between arteries and veins within the cavernous sinus and may be classified as either direct or dural.
Diagnosis and treatment of dural carotidcavernous fistulas. The most common sites of fistula are the rectum and the urinary organs, but almost any part of the body may be affected. Balloonassisted coiling of the cavernous sinus to treat. Cranial nerve palsies are regularly observed in patients with arteriovenous fistulas of the cavernous sinus. These fistulas usually result from some injury, like an automobile mishap or mugging. Wearing a helmet to prevent head trauma is a good way to avoid a carotid cavernous sinus fistulas. Carotid cavernous fistulas provide a free communication between the internal carotid artery and the surrounding cavernous sinus, resulting in high blood flow and high mean pressure in the shunt. The goal of ccf treatment is to completely occlude the fistula while preserving the normal. Carotidcavernous fistula presenting with bilateral abducens. Ccf can be classified based on the etiology traumatic or spontaneous, flow rate high or low flow, or the angiographic composition direct or. Diagnosis and management of dural carotid cavernous sinus fistulas neil r. A carotidcavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. It contains multiple venous channels extending from the endosteal dural layer of the sphenoid bone inferiorly and medially to the meningeal dural layer of the floor of the middle cranial fossa.
Pdf venous drainage patterns in carotid cavernous fistulas. Successful coil embolization of the fistula was performed with resolution of the infants. Nineteen patients were followed after interventional treatment. Ocular symptoms resolved by seven weeks, and he remained ocular symptom free at six months. Direct ccfs are characterized by a direct connection between the internal carotid artery ica and the cavernous sinus, whereas dural ccfs result from an indirect connection involving cavernous arterial branches and the cavernous sinus. Alteration of choroidal thickness in a case of carotid. Communicating carotidcavernous sinus fistula following minor head. Marginal sinus fistulas msfs are uncommon vascular anomalies. Carotidcavernous sinus fistulas and venous thrombosis. Pdf case report of endovascular therapy of indirect. Yeh cf, chen yh, lin ms, huang cc, hung cs, meng sw, lee ck, kao hl catheter cardiovasc interv 2018 mar 1. Images in clinical medicine from the new england journal of medicine carotidcavernous sinus fistula.
Symptoms range from benign ocular disturbances and cranial nerve palsies to severe or. Angiography is an essential tool for making a direct diagnosis and therapeutic determination of ccf. Direct carotid cavernous fistulas dccfs are abnormal arteriovenous shunts between the internal carotid artery ica and the cavernous sinus. Classification and treatment of carotid artery may induce spasm and decrease the flow in the spontaneous carotid cavernous sinus fistulas. The classic signs of a carotid cavernous fistula, including sudden onset of pulsating exophthalmos, a prominent bruit behind the affected eye, marked venous congestion and chemosis, impaired eye movement, and reduced visual acuity were present only in the patient with a traumatic direct internal carotid cavernous sinus fistula case 8. Pdf the benign course of carotidcavernous fistula in a.
These cases typically have a low flow and present with oculoorbital venous congestive features such as exophthalmos, chemosis, and sometimes oculomotor or abducens cranial nerve palsy. Indirect ccfs represent a subset of dural arteriovenous fistulas involving the cavernous sinus, which receive blood flow from meningeal branches of the internal andor external carotid arteries that normally supply the cavernous sinus dura 2, 26. Carotid cavernous fistula is usually a condition of trauma where the carotid artery becomes slightly torn in the cavernous sinus and allows arterial flow to occur into the veins of the cavernous sinus creating a high flow state to an area that normally handles low venous pressure. Traumatic carotidcavernous sinus fistula tccf is a rare but significant vascular abnormality in the skull base found after craniomaxillofacial trauma. Venous drainage patterns in carotid cavernous fistulas. Discussion direct and highflow internal carotid cavernous fistula ccf is endovascular embolization has become the primary treatment the abnormal communication between the internal carotid cav method for highflow, direct ccf.
The first category includes the direct fistula and is termed, by the angiographic classification of barrow, et al. The purpose of our study was to determine the longterm clinical outcomewith a special focus on extraocular muscular dysfunctionsin patients who had undergone endovascular treatment of a cavernous sinus fistula with detachable coils. When open at only one end it is called an incomplete fistula or sinus. Carotid cavernous fistula associated with persistent. The characteristic clinical features seen in patients with ccfs are. Carotid cavernous fistula ccf is an abnormal connection between the carotid arterial system and the cavernous sinus. Manual compression of the ipsilateral carotid artery and jugular vein can help.
Feb 25, 2021 carotid cavernous fistula ccf is an abnormal shunt from the carotid artery to the cavernous sinus. The patient was symptom free at the 8month followup. The mainstay of treatment of direct carotid cav communication between the internal carotid artery and ernous fistulas has been transarterial balloon emboliza the cavernous sinus and is usually high flow and trav tion of the affected cavernous sinus 3,4. This study compared ct angiography cta, mr angiography mra, and digital subtraction angiography dsa in elucidating the size and location of carotid cavernous sinus fistulas ccfs before embolization treatment. Rectal fistulas are often associated with colitis, cancer cancer, in medicine. Arteriovenous fistulas in the region of the cavernous sinus are commonly classified into two major categories based on the location of the fistula. Extension of a ccf into the sphenoid sinus presents additional management difficulties. The carotid cavernous fistula ccf is an abnormal arteriovenous communication and its drainage pathways may affect the clinic presentation and change treatment approach. Nakahara m, uozumi y, chiba y, miyake s, fujita a, kohmura e world neurosurg 2019 feb. A carotid cavernous fistula is an abnormal connection between the carotid artery or one of its branches and the venous system of the cavernous sinus draining the skull. Endovascular treatment of carotid cavernous sinus fistula.
Illustration of anatomicalangiographic categories of carotid cavernous sinus fistulas. Intracavernous carotid artery aneurysms causing a carotid cavernous fistula ccf are rare. Longterm outcome after coil embolization of cavernous. Long delayed traumatic carotidcavernous sinus fistula. Carotidcavernous fistulas are abnormal vascular shunts, allowing blood to flow either directly or indirectly from the carotid artery into the cavernous sinus. Pdf carotid cavernous fistula ccf is an abnormal communication between the cavernous sinus and the carotid arterial system. Ct angiography and mr angiography in the evaluation of carotid cavernous sinus fistula prior to embolization.
It may deprive the brain of oxygen and nutrients by shunting oxygenated blood to. Angiographic evaluation revealed a carotid cavernous fistula originating from a persistent trigeminal artery. External examination of the left eye of a 57yearold. Endovascular intervention is the firstline treatment of ccfs. Direct ccfs involve a tear or hole in a branch artery arising from the internal carotid artery within the cavernous sinus. Carotid cavernous fistula after endovascular intervention for chronic carotid artery total occlusion. Introductionthe ccf is an abnormal arteriovenous connection between the carotid artery and the venous cavernous sinus. Transvenous embolization of carotid cavernous fistula through. Digital subtraction angiography confirmed a lowflow indirect carotid cavernous fistula ccf. The cavernous sinus cs is a paired dural venous sinus centered around the sella turcica.
Pdf carotid cavernous fistula ccf is an abnormal communication between the. Although the direct type is usually caused by trauma, the onset of symptoms in tccf may present several weeks after injury. Endovascular interventions using various thrombogenic materials. The site must be allowed 6 to 8 weeks to mature before it can be cannulated. For direct, highflow ccfs, the transarterial route is preferred. A ct scan showed enlarged superior ophthalmic vein and cavernous sinus on the symptomatic side. Classification and treatment of spontaneous carotidcavernous sinus fistulas. A case report of a carotidcavernous sinus fistula, a rare complication following. Dural carotidcavernous fistulas dccfs constitute a rare condition caused by abnormal communications between meningeal branches of the internal or external carotid artery and the cavernous sinus, typically diagnosed in postmenopausal women. 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 draining veins, manifesting most dramatically as a. Ccfs are classified as direct or indirect, traumatic or spontaneous, and high or slow flow based on arterial supplies, etiology.
Cureus carotidcavernous sinus fistula masquerading as. Posttrauma exophthalmos caused by a carotid cavernous fistula. Introduction a case of communicating carotid cavernous sinus fistula ccf after. Carotid cavernous fistulae ccf are formed secondarily to abnormal communications. Caroticocavernous fistula radiology reference article. Posttrauma exophthalmos caused by a carotidcavernous fistula. An 11monthold female patient presented with symptoms of orbital venous congestion. Transcavernous repair of carotid cavernous fistula in. A vascular fistula can result from trauma to the head and neck. This permits blood flow from the carotid artery into the cavernous sinus, whether directly or indirectly. Direct ccfs are characterized by a direct connection between the internal carotid artery ica and the cavernous sinus, whereas dural. Multiple unilateral traumatic carotidcavernous sphenoid. A carotid cavernous fistula ccf is an abnormal arteriovenous connection between the internal carotid artery ica or the external carotid artery eca and the cavernous sinus.
The most commonly adopted classification is described by barrow based on arterial supply. Transvenous embolization of carotid cavernous fistula. Supraclinoid direct carotidcavernous sinus fistula bjr. We evaluated drainage patterns of ccfs by digital subtraction angiography dsa and categorized drainage pathways according to their types and etiology. It may form spontaneously or following trauma to the head.
This was a retrospective study of 53 patients with angiographically confirmed ccf. Carotid cavernous fistula due to a ruptured intracavernous. A carotid cavernous fistula ccf is an abnormal connection between the arteries and veins of the cavernous sinus. Treatment of carotid cavernous fistulas by cavernous sinus occlusion. Iatrogenic ccfs have been described as potential complications following aneurysm coiling, balloon angioplasty, and transsphenoidal surgery. Carotid artery cavernous sinus fistula, arteriovenous communication or arteriovenous fistula. Departments of ophthalmology, neurology, and neurosurgery, johns hopkins medical institutions, baltimore, maryland pa carotid cavernous sinus fistula ccf is an abnormal communication between the cavernous sinus and the carotid arterial system. However, some are iatrogenic, happening during a neurosurgical or interventional neuroradiological procedure. Ccfs are classified as direct or indirect, traumatic or spontaneous, and high or slow flow based on arterial supplies, etiology, and shunt flow rate, respectively. Ccfs are classified as direct or indirect, traumatic or spontaneous, and high or slow flow based on arterial supplies, etiology, and shunt flow rate, respectively 1. Three weeks into treatment both the fistula and the proptosis regressed. Treatment of carotidcavernous sinus fistulas using a.
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