Carotid cavernous fistula with bilateral thalamic infarct jeremy was suffering from a carotid cavernous fistula an abnormal connection between two blood vessels in his skull which impaired his vision and restricted his ability to. Caroticocavernous fistula radiology reference article. The suspected diagnosis of a direct carotidcavernous fistula ccf was confirmed by digital substraction arteriography. Type a ccfs are highflow direct shunts between the ica and the cavernous sinus fig. Cureus superior ophthalmic vein access for embolization. Similar results for manual compression in the treatment of indirect ccfs have been reported by other groups. Treatment of carotidcavernous fistula by muscle embolization and. Carotid cavernous fistula patients typically present with proptosis, elevated intraocular pressure, prominent tortuous conjunctival vessels, and sometimes headache. The woman underwent endovascular treatment with coiling of the cavernous sinus in combination with application of the onyx embolic agent in the fistula.
Carotidcavernous fistula ccf is a pathologic connection between the artery and the sinus that. A ptient is described with a ruptured intracavernous aneurysm causing a ccf resulting in acute onset of. Our aim is to study the varied posterior segment manifestations, level of visual impairment vi and its causes in carotid cavernous fistula ccf patients. Arteriovenous fistulae of the cavernous sinus are rare and difficult to diagnose. Endovascular repair of direct carotidcavernous fistula in. Carotid cavernous fistula in a patient with graves. Signs and symptoms are related to the compression of. The main symptom is diplopia, caused by compression injury of the oculomotor nerves. A carotid cavernous fistula ccf is an abnormal passage between the venous cavernous sinus and the internal carotid artery.
Carotid cavernous fistula due to a ruptured intracavernous. Carotid arterycavernous sinus fistula jama otolaryngology. Direct carotid cavernous fistula after trigeminal balloon. Classification and treatment of spontaneous carotid cavernous. Treating a carotid cavernous fistula with embolization involves placing small platinum coils where the abnormal connection is. The patient had a recent endovascular transvenous embolization that was only partially successful, with a residual carotid cavernous fistula draining to the left superior ophthalmic vein and multiple cortical veins.
Because of their propensity to form arterial dissections, aneurysms and rupture, they can develop carotidcavernous fistula ccf after. This is not surprising if the finding of cavernous carotid fistula in a patient with graves disease is to be considered purely coincidental. Carotid cavernous fistula an overview sciencedirect topics. On examination, elevated left intraocular pressure was found. Spontaneous resolution of posttraumatic direct carotid. Combined carotid artery and jugular vein compression resulted in a complete cure in seven of 23 patients 30% and improvement in one additional patient. This is the first indication for using the doubleballoon technique. Recent advances in endovascular techniques have resulted in several therapeutic modalities becoming available and the endovascular approach has evolved as the primary treatment option for the management of ccfs. They are classified into dural cavernous sinus fistulae or direct carotidcavernous fistulae. Imaging diagnosis of dural and direct cavernous carotid fistulae. Despite the similarity of symptoms between both types, a precise diagnosis is essential. Endovascular treatment of highflow carotid cavernous.
The maxillofacial surgeon must be able to diagnose this major complication of head trauma, use proper diagnostic techniques, and initiate appropriate therapeutic regimens. Arteriovenous fistula definition an arteriovenous fistula is an abnormal channel or passage between an artery and a vein. They are classified into dural cavernous sinus fistulae or direct carotid cavernous fistulae. Normally, oxygenated blood flows to the tissue through arteries and capillaries. The fistula leads to a highpressure inflow of arterial blood into the venous sinuses, resulting in compression and damage to adjacent structures. A carotidcavernous sinus fistula should be considered in a patient with chronic red eye present longer than four weeks. Cavernouscarotid fistula presenting with intracerebral. Urgent treatment of severe symptomatic direct carotid cavernous fistula caused by ruptured cavernous internal carotid artery aneurysm using highflow bypass, proximal ligation, and direct distal clipping.
The most frequent are type c, with meningeal branches of the external carotid forming the fistula 3. 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. Ccfs or dural arteriovenous fistulae of the cavernous sinus are. Following the release of oxygen in the tissues, the blood returns. Abstract full text pdf carotid cavernous fistulas ccfs are vascular shunts allowing blood to flow from the carotid artery into 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. However, it cannot pass through the fistula to enter the cs. We report a case of a direct carotidcavernous fistula ccf in a patient with ehlersdanlos syndrome type iv who presented with progressive chemosis and diplopia.
A carotidcavernous fistula is an abnormal communication between a carotid artery and the cavernous sinus. Posttraumatic carotidcavernous fistulas are due to a tear in the wall of. Intracavernous carotid artery aneurysms causing a carotidcavernous fistula ccf are rare. Four cases in which the diagnosis of carotidcavernous fistula was made by using ct angiography are illustrated. 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. A carotidcavernous fistula ccf is an abnormal communication between arteries and veins within the cavernous sinus and may be classified as. Interestingly, it has been reported that 20%60% of. Indirect carotid cavernous fistula embolisation using the superior. 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.
Type a are direct high flow shunts between the internal carotid artery and the cavernous sinus. The diagnosis was confirmed by digital subtraction angiography in all four instances. Visual impairment in high flow and low flow carotid. A 41 year old female presented with long standing history of redness of the left eye. Thirty symptomatic indirect carotid cavernous fistulas were treated between 1978 and 1986 with a variety of treatment modalities.
Bumpous, in complications in head and neck surgery second edition, 2009. Iatrogenic direct carotidcavernous fistulas ccfs are uncommon. With chemosis, ophthalmoplegia, and retroorbital pain, the auscultation of orbital bruit can make a correct and prompt diagnosis in the patient with carotid cavernous sinus fistula. Pdf doubleballoon technique for embolization of carotid. The anatomy of the lesion can vary, ranging from fistulas connecting the internal carotid artery or external carotid artery to the cs. The fistula was successfully treated angiographically. Traumatic carotidcavernous sinus fistula associated with an intradural pseudoaneurysm. Barrow dl, spector rh, braun if, landman ja, tindall sc, tindall gt. An initial cerebral angiogram revealed a large left direct carotid cavernous fistula. Indirect fistulas are due to communication by multiple branches between the internal andor external carotid arteries and the cavernous sinus. Type c ccfs are dural shunts between external carotid meningeal branches and the cavernous sinus fig. A carotid cavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. Carotidcavernous fistula and carotid artery aneurysm sonoworld. Because of their propensity to form arterial dissections, aneurysms and rupture, they can develop carotidcavernous fistula ccf after minor.
Communicating carotidcavernous sinus fistula following. This article is from march 2008 and may contain outdated material. These aneurysms usually cause neurological symptoms due to gradual expansion without rupture. A novel approach to the treatment of a direct carotid. The clinical presentation of ccfs, which is a direct consequence of elevation in intracavernous pressure and revised flow patterns, mostly comprises of ocular findings.
Spontaneous direct carotidcavernous fistula in an elderly. Carotidcavernous fistulas ccfs are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. 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. Patients with eds type iv can present with organ rupture, spontaneous arterial dissections and ruptured aneurysms. Carotidcavernous fistula an overview sciencedirect topics. Angiographic evidence of arterial steal from the left hemisphere was noted, with reversal of flow down the internal carotid artery ica to the fistula. Presented at meeting of the harvey cushing society philadelphia pa. Based on this classification, our case belongs to type a ii.
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. Iatrogenic carotidcavernous fistula secondary to endovascular. Visual impairment in high flow and low flow carotid cavernous. Assessment of cortical arterial circulation and collateral flow through. The initial signs and symptoms and subsequent course of 74 patients with carotidcavernous fistula were evaluated in relation to the prognosis for final visual acuity. Carotidcavernous sinus fistula endovascular procedures exophthalmos orbital cellulitis. Ehlersdanlos syndrome eds type iv is a collagen vascular disease with an autosomal dominant inheritance caused by col3a1 mutation. Complete occlusion of these fistulas with transvenous treatment alone has been reported in up to 81%. Carotid arterycavernous sinus fistula is a lesion most often associated with massive head trauma. Carotidcavernous sinus fistula definition of carotid. If they do rupture they most often lead to a ccf instead of bleeding into the subarachnoid space. May 24, 2019 carotid cavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. Lateralview right carotid angiogram shows carotid cavernous fistula arrow. Two thirds of the patients underwent carotid artery surgery because of the.
Browder j 1937 treatment of carotid artery cavernous sinus fistula. Signs and symptoms are related to the compression of structures within the cavernous sinus, including the. The characteristic clinical features seen in patients with ccfs are. Carotid cavernous fistula ccf is an abnormal communication between cavernous sinus and carotid arterial system. A cavernous carotid fistula ccf is an abnormal communication between the carotid artery and the cavernous sinus cs. Endovascular treatment of carotid cavernous sinus fistula. Four cases in which the diagnosis of carotid cavernous fistula was made by using ct angiography are illustrated. The conventional cerebral panangiography confirmed the diagnosis a direct carotidcavernous fistula ccf, with no evidence of ruptured aneurysm. Carotid cavernous sinus fistulas ccfs are abnormal communications between the carotid arterial system and the cavernous sinus. A carotid cavernous fistula is an abnormal communication between the carotid arterial system and the cavernous sinus. A case of communicating carotidcavernous sinus fistula ccf after minor closed head injury is presented. Treatment of carotid cavernous fistula secondary to rupture of a giant intracavernous carotid aneurysm 22 june 2016 interventional neuroradiology, vol.
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. Doctor answers on symptoms, diagnosis, treatment, and more. To prevent potential lethal arterial wall injury due to the fragility of the arterial vessel wall, the ipsilateral carotid artery and internal jugular vein were surgically exposed for direct insertion of endovascular sheaths. When a direct ccf is confirmed, firstline treatment is endovascular intervention, which may be accomplished using detachable balloons, coils. What is a carotid cavernous fistula doctor answers.
Urgent treatment of severe symptomatic direct carotid. Despite the similarity of symptoms between both types, a precise diagnosis is essential since the treatment is specific for each type of fistula. Caroticocavernous fistulas ccf represent abnormal communication between the carotid circulation and the cavernous sinus. Identification and confirmation of patency of outflow pathways of the cs. To our knowledge, this is the first report of the ct angiographic appearance of carotidcavernous fistulas.
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 lead to a deadly leak. As a result, the blood can drain properly from the eyes. A traumatic carotidcavernous fistula ccf connecting the internal carotid artery directly to the cavernous sinus is a potentially lifethreatening condition requiring urgent treatment, particularly in the presence of a pseudoaneurysm. Actually there is no reason why a patient with graves ophthalmopathy could not also develop other orbital processes, such as a primary or metastatic tumor or a carotid cavernous fistula. 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.
This separates the blood flow of the carotid arteries from that of the veins. May, 20 arteriovenous fistulae of the cavernous sinus are rare and difficult to diagnose. A carotidcavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. Carotidcavernous fistulas have been classified according to the hemodynamic properties, etiology, or anatomy of the fistula. In 1 patient with bilateral carotid cavernous fistulas, bilateral stent placement of both internal carotid arteries was done 1 day followed by coiling of 1 fistula on the following day and the second fistula 5 days later. 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. Carotid cavernous fistulas ccfs are a rare but potentially devastating cause of orbital symptoms, visual loss, and periocular disfigurement. Meaning of carotid cavernous sinus fistula medical term. The normal anatomy of the cavernous carotid and its surgical significance.
The patient had experienced a minor head injury 1 month ago with loss of consciousness. A lthough carotid arterycavernous sinus fistula was, in the words of hamby, the earliest recognized surgically treated intracranial vascular lesion, it is not. We present a case of a 53yearold male who presented with tinnitus, proptosis, conjunctivitis, and blurry vision. Dissectionrelated carotidcavernous fistula ccf following surgical. In rare instances, treatment requires direct endovascular access of. Direct carotidcavernous fistula ccf is an uncommon but well known complication of head trauma. A case of rightsided direct carotid cavernous fistula.
Intracavernous carotid artery aneurysms causing a carotid cavernous fistula ccf are rare. Balloon catheters for investigating carotid cavernous fistulas. The left hemisphere filled through the anterior communicating artery. Clinical features of a carotidcavernous sinus fistula include tortuous corkscrew episcleral vessels, chemosis, asymmetric intraocular pressure, proptosis and an orbital bruit. Carotidcavernous fistula knowledge for medical students. Carotidcavernous fistula may result from the down fracture of the maxilla or the pterygoid osteotomy, thus injuring the internal carotid artery.
Imaging diagnosis of dural and direct cavernous carotid. Carotid cavernous fistulas have been classified according to the hemodynamic properties, etiology, or anatomy of the fistula. Treatment of a traumatic carotidcavernous fistula by the. In 4 of the carotid cavernous fistulas, coiling of the fistula was performed in the same session as stent placement. 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. Looking for online definition of carotid cavernous sinus fistula in the medical dictionary. A 45yearold caucasian male presented to the emergency department of a tertiary care hospital with the chief complaint of blurred vision and facial numbness. 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. Pdf carotid cavernous fistula ccf is an abnormal communication between the cavernous sinus and the carotid arterial system. Carotid cavernous fistula may result from the down fracture of the maxilla or the pterygoid osteotomy, thus injuring the internal carotid artery. The characteristic clinical features seen in patients with ccfs are the sequelae of hemodynamic dysfunction within the cavernous sinus.
Carotid cavernous fistulas are abnormal vascular shunts, allowing blood to flow either directly or indirectly from the carotid artery into the cavernous sinus. These lesions may be classified based on the following. Carotid cavernous fistulas ccfs are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. Five patients underwent treatment with selfexpanding stents due to intraprocedural ccf and ica dissection following surgical removal of icao. Carotidcavernous fistulas are abnormal vascular shunts, allowing blood to flow either directly or indirectly from the carotid artery into the cavernous sinus. Description an arteriovenous fistula is a disruption of the normal blood flow pattern. Traumatic carotid cavernous fistula accompanying basilar skull fracture. Two thirds of the patients underwent carotid artery surgery because of the fistula. Classification and treatment of spontaneous carotidcavernous sinus fistulas. To identify associated cavernous carotid aneurysms. Ccfs usually develop after head trauma but can occur spontaneously. To our knowledge, this is the first report of the ct angiographic appearance of carotid cavernous fistulas. Ccfs can be classified by anatomy direct or dural, etiology traumatic or sponta.
Presented at meeting of the harvey cushing society philadelphia, pa. A woman with a red eye from a carotidcavernous sinus fistula. Carotidcavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. A balloon arrow is sucked to the fistula in the ica.
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