This article is from march 2008 and may contain outdated material. Carotid cavernous fistula ccf is an abnormal communication between cavernous sinus and carotid arterial system. Despite the similarity of symptoms between both types, a precise diagnosis is essential since the treatment is specific for each type of fistula. A 59yearold woman presented with headache, right pulsatile tinnitus, and diplopia on the right side. Carotid cavernous fistula may result from the down fracture of the maxilla or the pterygoid osteotomy, thus injuring the internal carotid artery. The most frequent are type c, with meningeal branches of the external carotid forming the fistula 3. Presentation and treatment of carotid cavernous aneurysms. Treatment of a traumatic carotidcavernous fistula by the.
Carotid cavernous fistula patients typically present with proptosis, elevated intraocular pressure, prominent tortuous conjunctival vessels, and sometimes headache. Carotid cavernous sinus fistula carotid artery cavernous. Selfmade detachable balloon catheters, coils and glue were used in this group of cases and good results obtained. Carotid cavernous fistulas ccfs are a rare but potentially devastating cause of orbital symptoms, visual loss, and periocular disfigurement. Liang w, xiaofeng y, weiguo l, wusi q, gang s, xuesheng z. Treating a carotid cavernous fistula with embolization involves placing small platinum coils where the abnormal connection is. In our experience over the past 2 decades, most type a fistulas have a rather discrete laceration of. 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. Pdf carotidcavernous fistula in the emergency department. A carotid cavernous sinus fistula is such a channel, that is formed between the carotid artery, one of the major arteries of the body, and the cavernous sinus, a venous sinus that lies within the head.
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. Carotid endarterectomy pdf veterans health library. Treatment of carotid cavernous fistulas springerlink. When transvenous access is not possible, an alternate approach must be devised. The most common method of treatment for these lesions is transvenous endovascular embolization via the inferior petrosal sinus or the facial vein. A carotid cavernous sinus fistula should be considered in a patient with chronic red eye present longer than four weeks. Most often, ccfs are broadly classified as either direct or indirect, on the basis of anatomic features depicted on angiograms. Ppt carotid cavernous fistula powerpoint presentation. These first five cta images of the head demonstrate filling of the left cavernous sinus in the arterial phase and asymmetric enlargement and filling of the left superior ophthalmic vein.
The authors report a rare case of a carotidcavernous fistula ccf secondary to ehlersdanlos syndrome eds type iv which showed an aggressive angiographical change. Surgery carotid fistula embolization surgery beaumont health. Endovascular tve for dccf is used for curative purposes, but serious complications can be caused with inadequate embolization. Spontaneous carotid cavernous sinus fistulas have been associated with the presence of ruptured carotid aneurysms, atherosclerosis, diabetes mellitus, and genetic disorders such as. Carotid cavernous fistula definition of carotid cavernous. Carotid cavernous fistula ccf is an abnormal communication between the cavernous sinus and the carotid arterial system. Signs and symptoms are related to the compression of structures within the cavernous sinus, including the. Data from 163 treated hypertensive men who were volunteers for a free medical. Transvenous embolization of dural carotid cavernous fistulas. Transcavernous repair of carotid cavernous fistula in. A, left external carotid angiogram, anteriorposterior view, showing shunt flow into the left cavernous sinus. 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.
Cureus transorbital approach for endovascular occlusion. It may be a result of trauma to the head, or it may develop spontaneously, particularly in middleaged women. Treatment of carotid cavernous fistula by muscle embolization alone. Increased pressure within the cs seems to be the mainstay of pathophysiology, although arterial steal and increased flow plays an important role. Case 3 a 30yearold man had severe head trauma 12 months before.
In addition to conservative measures, carotid jugular compression at the level of the carotid bulb can be useful in the treatment of indirect fistulas resulting in closure in up to 30% of cases, presumably due to progressive thrombosis due to intermittent stagnation of blood adjacent to existing clot. It is classified into 4 types including a, b, c and d according to barrow d in 1985 1. Anatomy and surgery of the cavernous sinus vinko v. If they do rupture they most often lead to a ccf instead of bleeding into the subarachnoid space. 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. 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. Carotid cavernous fistula ccf is an abnormal communication between the carotid artery ca and cavernous sinus cs. Young men are at highest risk, as the major cause is head trauma. Bmode and color doppler ultrasonography cdus are the methods of choice for screening and determining the degree of carotid artery stenosis.
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. Ccfs are classified using the barrow classification. Drainage is toward the ips and the contralateral ips through the intercavernous sinus. A series of 54 traumatic carotid cavernous fistulas has been treated with detachable balloon catheters. Kennerdell, md, chair, department of ophthalmology, allegheny general hospital professor, ophthalmology, drexel university. 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. 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. Mar 30, 2020 a carotidcavernous fistula is a vascular disorder in the cavernous sinus region of the skull. Ccf represents an abnormal communication from the carotid artery to the cavernous sinus. Intracavernous carotid artery aneurysms causing a carotid cavernous fistula ccf are rare. 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. If detected early, the condition can be easily treated with an. Diagnostic vascular ultrasonography with the help of color doppler. A woman with a red eye from a carotidcavernous sinus.
Direct carotid cavernous fistulas are highflow shunts with a direct connection between the internal carotid artery and. Carotidcavernous fistula an overview sciencedirect topics. Carotid cavernous fistulas ccf5 are abnormal communications between the carotid artery or its dural branches and the cavernous sinus. A carotid cavernous fistula ccf is an abnormal passage between the venous cavernous sinus and the internal carotid artery. Surgical exposure and direct access to the superior ophthalmic vein have been previously described in situations in which conventional transvenous access, including the inferior petrosal sinus, is not possible. Carotid cavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus.
Posttraumatic carotid cavernous fistula is a very rare complication that can occur in patients with craniomaxillofacial trauma. Direct carotid cavernous fistulas are highflow shunts with a direct connection between the internal carotid. Carotidcavernous fistula kennerdell case 26, ppt eccles. Ccf is an abnormal communication between carotid arterial system internal carotid artery ica or external carotid artery eca and cavernous sinus cs fig. Pdf carotid cavernous fistulas ccf are vascular communications between the carotid artery and the cavernous sinus. Carotid sinus reflex death is a potential etiology of sudden death in which manual stimulation of the carotid sinus allegedly causes strong glossopharyngeal nerve vagus nerve is for aortic arch baroreceptors impulses leading to terminal cardiac arrest. Pdf download for carotid artery ultrasound image analysis. Imaging diagnosis of dural and direct cavernous carotid. They are classified into dural cavernous sinus fistulae or direct carotid cavernous fistulae. Carotidcavernous fistula presenting with bilateral. Doctor answers on symptoms, diagnosis, treatment, and more. Treatment of carotid cavernous fistulas northwestern scholars. Ccfs arise from abnormal communications between the carotid arteries and the cavernous sinus. Caroticocavernous fistula radiology reference article.
Carotidcavernous fistula as a complication of facial trauma. Clinical features of a carotid cavernous sinus fistula include tortuous corkscrew episcleral vessels, chemosis, asymmetric intraocular pressure, proptosis and an orbital bruit. The carotid atherosclerotic plaque model was established in new. 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. A ptient is described with a ruptured intracavernous aneurysm causing a ccf resulting in acute onset of. 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. Our aim was to report clinical characteristics, angiographic findings, and results of endovascular tve in patients presenting with dccf. Carotidcavernous fistulas ccfs are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. 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. Traumatic carotidcavernous fistula presenting as massive. The decision of harvey cushing to leave general surgery and concentrate on the infant field of central nervous system surgery was in retrospect a landmark in the history of neurosurgery. 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.
Carotid cavernous fistulae ccfs are spontaneous or acquired communications between the carotid artery and the cavernous sinus. No death related to the embolisation procedures occurred in our group. Presented at meeting of the harvey cushing society philadelphia pa. Of the 10 orbital arteriovenous shunts showing signs of dural fistulas, the features disappeared in 8 cases, although after a much longer followup period than for the typical dural carotid cavernous sinus fistulas. Treatment of carotid artery cavernous sinus fistula. Ccfs can be classified by anatomy direct or dural, etiology traumatic or spontaneous or blood flow velocity high or low. A ccf can be due to a direct connection between the cavernous segment of. Internal occlusion of a carotidcavernous fistula in. Department of neurological surgery, university of virginia 2. Symptoms involve headache, diplopia, ptosis of the upper lid, conjunctival chemosis, pulsating exophthalmos, and ophthalmoplegia. A carotid cavernous fistula is an abnormal communication between the carotid arterial system and the cavernous sinus. Carotidcavernous fistula kennerdell case 26, ppt creator john s. Arteriosclerosis, thrombosis, and vascular biology atvb. The diagnostic angiography demonstrated a right ccf.
In most instances, endovascular treatment is preferred. This pdf is available for free download from a site hosted by medknow publications. Carotid cavernous fistula is an abnormal arteriovenous communication between the carotid artery or its branches and the cavernous sinus. A carotid cavernous fistula is a vascular disorder in the cavernous sinus region of the skull.
Presented at meeting of the harvey cushing society philadelphia, pa. Most good results from carotid ligation occur in small, lowflow fistulas. Flow voids within the cavernous sinuses andor certain venous drainage on spinecho mr imaging and timeofflight tof flow enhancement on mr angiography mra have indicated highvelocity shunt flow and have been used for screening patients with dural arteriovenous fistulas davfs of the cavernous sinuses. A 45yearold caucasian male presented to the emergency department of a tertiary care. This separates the blood flow of the carotid arteries from that of the veins. 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. The adobe flash plugin is needed to view this content. Carotid fistula embolization is accomplished by endovascular closure of the fistula. Advances in the endovascular treatment of direct carotid.
Oct 28, 2015 carotid cavernous fistulas ccfs are abnormal communications between the carotid arterial system and the venous cavernous sinus. The normal anatomy of the cavernous carotid and its surgical significance. Short telomeres are associated with increased carotid. A carotid cavernous sinus fistula is an anomalous communication of dural branches from the intracerebral artery or external carotid artery to the cavernous sinus. A surgical approach to the cavernous portion of the. Highflow ccfs result from a direct connection between the intracavernous carotid artery and the surrounding cavernous sinus. Magnetic resonance angiography source images in carotid. Carotid cavernous fistula an overview sciencedirect topics. Four cases in which the diagnosis of carotid cavernous fistula was made by using ct angiography are illustrated.
Outcome of carotidcavernous fistula embolization with onyx. In this retrospective study of 20 patients, we report. Closure of carotid cavernous sinus fistulae by external compression of the carotid artery and jugular vein. A carotid cavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. Treatment of 54 traumatic carotidcavernous fistulas in. From 1986 to the end of 1998,482 cases of traumatic carotidcavernous fistula tccf were treated by means of intravascular embolisation technique. To our knowledge, this is the first report of the ct angiographic appearance of carotid cavernous fistulas. Dural carotid cavernous fistulas are usually treated via a transvenous approach through the inferior petrosal sinus. They are postulated to occur secondary to cavernous sinus thrombosis with revascularization and thus. Carotid cavernous sinus fistula and aneurysmal rupture associated with fibromuscular dysplasia. 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. Ppt carotid cavernous fistula powerpoint presentation free to download id. The fistula was successfully treated angiographically.
Diagnosis and management of carotid cavernous fistulas. Carotid cavernous fistulas ccfs pose an anatomically and physiologically challenging problem for clinicians. What is a carotid cavernous fistula doctor answers. B, left internal carotid angiogram, lateral view, showing a dural arteriovenous fistula at the posterior cavernous sinus.
A case of communicating carotid cavernous sinus fistula ccf after minor closed head injury is presented. Urgent treatment of severe symptomatic direct carotid. Feb 10, 2017 these first five cta images of the head demonstrate filling of the left cavernous sinus in the arterial phase and asymmetric enlargement and filling of the left superior ophthalmic vein. Indirect fistulas are due to communication by multiple branches between the internal andor external carotid arteries and the cavernous sinus. To the best of our knowledge, this is the first reported case of a spontaneous direct, highflow carotid cavernous fistula in infancy. Direct carotid cavernous fistula ccf is an uncommon but well known complication of head trauma. They were kept at a constant room temperature, with free access to water. Barrow classification of caroticocavernous fistulae. Endovascular treatment strategy for direct carotid cavernous fistulas resulting from rupture of intracavernous carotid aneurysms.
As a result, the blood can drain properly from the eyes. The balloon was introduced through one of three different approaches. A carotidcavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. These lesions may be classified based on the following. The diagnosis was confirmed by digital subtraction angiography in all four instances. Peng, md, department of neurology, yale school of medicine, 15 york st, llci 910, po box 208018, new haven, ct 06520. Peng and others published carotid cavernous fistula presenting with bilateral abducens palsy find, read and cite all the research you need on researchgate. The characteristic clinical features seen in patients with ccfs are.
This article is from june 2005 and may contain outdated material. Carotid cavernous fistula due to a ruptured intracavernous. Pdf glaucoma management in carotid cavernous fistula. Carotid cavernous fistulas are abnormal communications between the carotid artery and the cavernous sinus, either directly or via intradural branches of the internal or external carotid arteries. Based on this classification, our case belongs to type a ii.
The cavernous segment of the carotid artery is unique, as it is the only anatomical location in the body where an artery is completely surrounded by a venous structure. Carotid cavernous fistula is abnormal shunting between carotid arteries and the cavernous sinus. Autologous bone marrow mononuclear cell transplantation delays. 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. Ccf can be traumatic or spontaneous, with the traumatic type being more common, representing 75% of all ccfs. Aggressive change of a carotidcavernous fistula in a patient. Most type a carotid cavernous fistulas are high flow and traumatic in origin. These aneurysms usually cause neurological symptoms due to gradual expansion without rupture. Ctaguided outflowtargeted embolization of direct carotidcavernous fistula duration. Type a is direct highflow shunts between the internal carotid artery ica and the cavernous sinus. Nearly all patients with a direct carotid cavernous sinus fistula experience progressive ocular complications if the fistula is left untreated. The existence of susceptible plaque in the carotid artery can be used in. A sheath is placed in the femoral artery in the groin, and a catheter is used to obtain a cerebral angiogram. Traumatic carotid cavernous fistula accompanying basilar skull fracture.
Barrow caroticocavernous fistula classification divides caroticocavernous fistulas into direct type a or indirect types bd. Carotidcavernous and orbital arteriovenous fistulas. Common carotid intimamedia thickness and risk of stroke. Enlarged cavernous sinus with a convex shape to the lateral. We describe a case example with bilateral barrow type b.
The shunting of the blood may produce ocular ischemia 503 and may transmit arterial pulsations. Symptoms and signs are usually related to orbital congestion caused by retrograde filling of the ophthalmic veins from the cavernous sinus 3,4. Carotidcavernous fistula and carotid artery aneurysm. Arteriovenous fistulae of the cavernous sinus are rare and difficult to diagnose. Carotidcavernous fistula definition of carotidcavernous. Internal carotid artery ica stenosis quantification is essential for the clinical management of patients, since several trials have concluded that. Endovascular treatment of highflow carotid cavernous. A free powerpoint ppt presentation displayed as a flash slide show on id. We performed a retrospective analysis of 44 consecutive patients with dccf treated by. Carotidcavernous sinus fistulae ccf are extremely rare and can be classified as traumatic or spontaneous, direct when the fistula is directly off of the internal carotid artery ica or indirect when the fistula is from a branch of the ica and low or high flow. Report of 32 surgically treated cases and suggestions for.
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