Typea fistulas rarely resolve spontaneously because of high flow fistula enlarges, causing decreased. A carotidcavernous fistula ccf consists of abnormal communications between the cs and branches of either the internal carotid artery ica or the external carotid artery eca. If you continue browsing the site, you agree to the use of cookies on this website. 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 sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. Treatment of a traumatic carotidcavernous fistula by the. To describe the etiology and clinical presentaton of carotid cavernous fistulas. Barrow caroticocavernous fistula classification divides caroticocavernous fistulas into direct type a or indirect types bd. These aneurysms usually cause neurological symptoms due to gradual expansion without rupture. Endovascular treatment strategy for direct carotid cavernous fistulas resulting from rupture of intracavernous carotid aneurysms. 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. Apr 15, 2020 this case study reports the diagnosis and treatment of a carotid cavernous sinus fistula that developed several months after a traumatic head injury.
The present study describes a case of direct posttraumatic carotid cavernous fistula in a 26 years old man. But treatment success rates for these fistulas now approach 100. Spontaneous fistulas usually have low rates of arterial blood flow and result in less severe symptoms. A ptient is described with a ruptured intracavernous aneurysm causing a. Carotid cavernous sinus fistulae are rare, but serious, vascular anomalies which may develop following traumatic injury to the skull base. The most frequent are type c, with meningeal branches of the external carotid forming the fistula 3. Carotidcavernous fistulas ccfs are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. Barrow dl, spector rh, braun if, landman ja, tindall sc, tindall gt.
Ruptured cavernous sinus aneurysms causing carotid cavernous fistula. A traumatic carotid cavernous 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. This frontal view shows the enlarged left carotid cavernous sinus fistula right compared to the normal right cavernous sinus left. These lesions may be classified based on the following. Oct 28, 2015 carotid cavernous fistulas ccfs are abnormal communications between the carotid arterial system and the venous cavernous sinus. Recurrent carotid cavernous fistula originating from a giant cerebral aneurysm after placement of a covered stent jung wook baek1, sung tae kim1, young seo lee1, younggyun jeong1, hae woong jeong2, jin wook baek2, jung hwa seo3 departments of 1neurosurgery, 2diagnostic radiology, and 3neurology, busan paik hospital, inje university, school. Diagnosis and management of carotid cavernous fistulas. As a result, the blood can drain properly from the eyes. Traumatic arteriovenous pial fistula masquerading as a carotid cavernous fistula. Classification and treatment of spontaneous carotid cavernous sinus fistulas. Final lateral angiogram shows reconstruction of the left carotid artery and closure of the direct carotid cavernous fistula. Traumatic carotid cavernous fistula accompanying basilar skull fracture. Carotid cavernous fistula patients typically present with proptosis, elevated intraocular pressure, prominent tortuous conjunctival vessels, and sometimes headache.
A carotid cavernous fistula ccf is an abnormal passage between the venous cavernous sinus and the internal carotid artery. Carotidcavernous fistula an overview sciencedirect topics. Campbell, ddst the cavernous sinuses and associated structures comprise a unique and intricate physioanatomic unit. This separates the blood flow of the carotid arteries from that of the veins. Increased pressure within the cs seems to be the mainstay of pathophysiology, although arterial steal and increased flow plays an important role. This article is from march 2008 and may contain outdated material. Clinical features of a carotid cavernous sinus fistula include tortuous corkscrew episcleral vessels, chemosis, asymmetric intraocular pressure, proptosis and an orbital bruit. Ccfs can be classified by anatomy direct or dural, etiology traumatic or sponta. Endovascular embolization is the standard approach for management of carotid cavernous fistulas ccfs due to the ease of access and reduced level of risk associated with the procedure compared with open surgery.
A 45yearold caucasian male presented to the emergency department of a tertiary care. Carotid cavernous fistula ccf is the abnormal communication between the internal carotid artery and the cavernous sinus. Furthermore, we present the images that we used to make the diagnosis. Advances in the endovascular treatment of direct carotid. We describe an unconventional endovascular approach in a young patient with large highflow traumatic carotid cavernous fistula that could not be treated by detachable balloon procedure.
If there is no threat to vision, simply follow asymptomatic dural arteriovenous fistulas. A carotid cavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. Introduction 9 carotid cavernous fistulae ccf are abnormal communications between the internal carotid artery ica and venous compartments of the cavernous sinus. A ccf can be due to a direct connection between the cavernous segment of. Combined surgical and endovascular approach to treat a. Endovascular treatment for type a ccf with detachable coils 78 j kor neurotraumatol soc 2008. The cavernous portion of the internal carotid artery was filled via anastomoses between the internal maxillary artery and the artery to the inferior cavernous sinus fig. The potentially sightrobbing vascular abnormality known as the carotidcavernous sinus fistula ccf can masquerade as conjunctivitis or other common ocular conditions, which diminishes the chance for a speedy diagnosis. Fractures or the shearing forces of severe head trauma. A cavernous carotid fistula ccf is an abnormal communication between the carotid artery and the cavernous sinus cs. Diagnosis and classification with timeresolved mr angiography at 3t r. Treatment of carotid cavernous fistulas springerlink.
The anatomy of the lesion can vary, ranging from fistulas connecting the internal carotid artery or external carotid artery to the cs. These fistulae can occur because of trauma, if there is an aneursym in the carotid that breaks and causes the communication, or they can happen. Key method seven patients with vascular disease four with cavernous and two with transverse sinus dural fistulas and one with a facial arteriovenous malformation, all supplied primarily from cavernous branches of the internal carotid artery underwent subselective catheterization and embolization. There is outflow into the ophthalmic veins and cortical veins. A 55yearold woman with a long history of hypertension presented to the hospital with a. If the internal carotid artery ruptures within the cavernous sinus, an arteriovenous fistula is created more specifically, a carotid cavernous fistula. 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. Young men are at highest risk, as the major cause is head trauma.
Vascular lesions of the cavernous sinus namely, cavernous sinus thrombosis, ica aneurysm, and ccfare great clinical mimics, with a wide variety of clinical manifestations varying. A, right internal carotid injection, lateral projection, shows carotid cavernous fistula arising from anterior inferior carotid siphon, with drainage to the. Ccfs can be classified in a number of ways based on etiology traumatic or spontaneous, rate of flow low vs high, and the angiographic structure direct or indirect. May 24, 2019 carotid cavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. Endovascular treatment of carotid cavernous fistulae. Dexamethasone may be used while waiting for definitive diagnosis and treatment. Carotid cavernous fistula carotid cavernous fistulae are a specific kind of dural fistula that involves the carotid artery or its branches and a large vein cavernous sinus behind the eye. Superior ophthalmic vein access for embolization of an. Two coronary stentgrafts were used to close the large tear of. All 9 patients were treated with endovascular detachable coils, via the transarterial approach. Carotidcavernous sinus fistula definition of carotid. 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.
Barrow classification of caroticocavernous fistulae. Endovascular treatment for type a carotid cavernous. This was a prospective cohort study consisting of 60 patients diagnosed with carotid cavernous fistula. Cavernouscarotid fistula definition of cavernouscarotid. Endovascular treatment for type a carotid cavernous fistulas. Embolization of branches arising from the cavernous. A woman with a red eye from a carotidcavernous sinus. Recurrent carotid cavernous fistula originating from a giant. These features included presence of a pseudoaneurysm, large varix of the cavernous sinus, venous drainage to cortical veins, and thrombosis of venous outflow pathways distant from the fistula. May 15, 2001 from 1986 to the end of 1998, 482 cases of traumatic carotid cavernous fistula tccf were treated by means of intravascular embolisation technique. Spontaneous direct carotidcavernous fistula in an elderly. Caroticocavernous fistula radiology reference article. Signs and symptoms are related to the compression of structures within the cavernous sinus, including the.
If they do rupture they most often lead to a ccf instead of bleeding into the subarachnoid space. Carotid cavernous fistula is an abnormal arteriovenous communication between the carotid artery or its branches and the cavernous sinus. A 52yearold woman had a cerebrovascular accident with residual left facial weakness. Patients present with proptosis, ecchymosis redness, and pain around the affected eye. Carotid cavernous fistula was one of the first intracranial vascular lesions to be recognized. Carotid cavernous fistulas have been classified according to the hemodynamic properties, etiology, or anatomy of the fistula table 1. We report our experience of using a commercially available form of timeresolved mr angiography trmra at 3t for the diagnosis and classification of a cranial davf compared with the reference standard of digital subtraction. Craniofacial trauma is a major factor for this complication. A carotidcavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. Symptoms are often abrupt in onset and rapidly progressive, and ccf requires immediate treatment if there is progressive visual impairment. Collateral pathways between the cavernous portion of the. Itsentrance into the cavernous sinus isfrequently demarcated byabandlike impression ofthe dura.
Hemodynamic classification refers to whether the fistula is high or low flow. 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. With ct, mr, and angiography, we examined 12 cases of spontaneous carotid cavernous fistula, five of whom presented only with cranial nerve palsies. Ccf is an abnormal communication between carotid arterial system internal carotid artery ica or external carotid artery eca and cavernous sinus cs fig. 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. Carotid cavernous fistulae ccfs are abnormal communications between the internal or external carotid arteries and the cavernous sinus. Transarterial platinum coil embolization of carotid. In this light, we decided to treat this case with endovascular approach after considering several therapeutic options. The nerve passes inferiorly and laterally, to lie between the internal carotid artery and jugular vein, superficial to the. Etiology is commonly secondary to trauma or can occur spontaneously in the setting of. 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. There are a number of causes, however, aneurysm rupture and trauma are by far the most common. Iatrogenic carotidcavernous fistula after stent assisted. 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.
Drainage is toward the ips and the contralateral ips through the intercavernous sinus. A, left external carotid angiogram, anteriorposterior view, showing shunt flow into the left cavernous sinus. Carotid cavernous fistula may result from the down fracture of the maxilla or the pterygoid osteotomy, thus injuring the internal carotid artery. Carotid cavernous fistulas are abnormal vascular shunts, allowing blood to flow either directly or indirectly from the carotid artery into the cavernous sinus. Carotid cavernous fistulas ccfs are a rare but potentially devastating cause of orbital symptoms, visual loss, and periocular disfigurement. Carotid cavernous sinus fistula ccf is a rare disorder that arises due to an abnormal communication between the cavernous sinus and the carotid arterial system, which may be divided into spontaneous or traumatic in relation to cause 12.
In most instances, endovascular treatment is preferred. Treating a carotid cavernous fistula with embolization involves placing small platinum coils where the abnormal connection is. Indirect fistulas are due to communication by multiple branches between the internal andor external carotid arteries and the cavernous sinus. Pdf carotidcavernous fistula in the emergency department. A case of communicating carotid cavernous sinus fistula ccf after minor closed head injury is presented.
These fistulas usually result from some injury, like an automobile mishap or mugging. Highflow direct ccfs usually are traumatic or are caused by rupture of a cavernous aneurysm into the sinus, but a small percentage can be spontaneous. The characteristic clinical features seen in patients with ccfs are. Direct carotid cavernous fistula ccf is an uncommon but well known complication of head trauma. The conventional cerebral panangiography confirmed the diagnosis a direct carotid cavernous fistula ccf, with no evidence of ruptured aneurysm. Within the cavernous sinus, the internal carotid artery issituated between layers of the dura mater forming the sinus. Traumatic carotidcavernous fistula tccf arises from head injury and results in a direct shunt between the internal carotid artery ica and the cavernous sinus, which usually occurs in young men. Clinical signs and symptoms that characterized a hazardous carotid cavernous fistula included increased intracranial pressure, rapidly progressive. To describe the approach to endovascular treatment. Introduction carotid cavernous fistula ccf is the abnormal communication between the internal carotid artery and the cavernous sinus.
Intracavernous carotid artery aneurysms causing a carotid cavernous fistula ccf are rare. 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 are classified using the barrow classification. 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. Carotid cavernous fistula carotid cavernous fistulas are a specific type of abnormal connection of the arteries directly into the venous system. These veins at the back of your eye transport blood from your face and brain back to your heart and are located in small spaces behind your eyes called cavernous sinuses. They are commonly classified based on hemodynamics, etiology or anatomically. The preferred treatment for traumatic carotid cavernous fistula tccf is to.
A ccf can be due to a direct connection between the cavernous segment of the internal carotid artery and the cavernous sinus, or. Carotid cavernous fistula due to a ruptured intracavernous. The initial portion ofthe sshaped cavernous carotid artery ascends toward the posterior clinoid process forming, then. The diagnosis of dural arteriovenous fistula davf remains one of the few uncontested indications for catheter based cerebral angiography. Original article a retrospective analysis of 38 carotid. Classification and treatment of spontaneous carotid. Anomalous communication between the internal carotid artery ica or its branches andor branches of the external carotid artery eca with the cavernous sinus causes an abrupt change in the direction and distribution of brain and orbital blood flow an uncommon condition of varying severity. A red eye induced by a spontaneous carotid cavernous fistula. Spontaneous carotid cavernous fistula presenting only with. 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. Early diagnosis of this rare vascular complication can preserve vision.
Lesions affecting the cavernous sinus may affect isolated nerves or all the nerves traversing through it. Carotid cavernous fistula coilendovascular treatment head trauma. Carotid cavernous fistula trh9 3 treatment in acute setting of vision loss cn paralysis, glucocorticoids e. To the best of our knowledge, this is the first reported case of a spontaneous direct, highflow carotid cavernous fistula in infancy. We present here a case of a ccf that eventually led to the development of brainstem venous congestion from perimedullary venous drainage. The cause of fistula is etiologically spontaneous and mostly traumatic 75%. The woman underwent endovascular treatment with coiling of the cavernous sinus in combination with application of the onyx embolic agent in the fistula. Carotid cavernous fistula joseph niamtu, iii, dds, and robert l. To describe the management and outcomes in a series of 8 cases of carotid. Many kinds of detachable balloon catheters including chinese. Although the types, manifestations, and treatment options of carotid cavernous fistulas have been extensively discussed in the current literature, most of this knowledge is based on an older population. Meaning of carotid cavernous sinus fistula medical term. Most often, ccfs are broadly classified as either direct or indirect, on the basis of anatomic features depicted on angiograms.
Iatrogenic carotid cavernous fistula after stent assisted coil embolization of posterior communicating artery aneurysm hyeran park, seokmann yoon, jaijoon shim, hackgun bae, ilgyu yun department of neurosurgery, soonchunhyang university cheonan hospital, cheonan, korea stent assisted coiling sac is a useful technique for the treatment of. A direct fistula is due to direct communication between the intracavernous internal carotid artery and the surrounding cavernous sinus. Pdf traumatic arteriovenous pial fistula masquerading. Looking for online definition of carotid cavernous sinus fistula in the medical dictionary. Carotid cavernous fistula ccf is an abnormal vascular shunt from the carotid artery to the cavernous sinus. Ten branches were catheterized seven meningohypophyseal trunks and three. The pituitary gland lies between the two paired cavernous sinuses.
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