Carotid-cavernous Fistula Research Articles

Delayed Onset of a Contralateral "White-Eyed Shunt" Posterior Draining Carotid-Cavernous Fistula Following Ipsilateral "Red-Eyed Shunt".

Delayed Onset of a Contralateral "White-Eyed Shunt" Posterior Draining Carotid-Cavernous Fistula Following Ipsilateral "Red-Eyed Shunt".

Correlation of Clinical Presentations and Imaging Findings with Flow Dynamics in Carotid-Cavernous Fistula Patients at Dr. Hasan Sadikin Hospital, Bandung

Background: Carotid cavernous fistulas (CCFs) have variable clinical presentation, imaging, and angiographic findings. The study aims to investigate the association of clinical presentations and radiological findings with flow dynamics from digital subtraction angiography (DSA) of CCFs patients.
 Methods: CCF patients who underwent DSA at Dr. Hasan Sadikin general hospital from January 2017 – December 2019 were included in this study. Patient’s characteristics, clinical presentations, and imaging results were retrieved from the patient’s medical record and radiology database. Fractures, proptosis, extraocular muscle thickening, superior ophthalmic vein dilatation, cavernous hyperdense lesion, and infarct are expected to be identified from imaging results. DSA identified types of flow dynamic based on Barrow classification and venous drainage patterns. Numeric data were analyzed by using Mann Whitney test, while categorical data were analyzed with Fisher’s exact test.
 Results: Twenty-eight patients were included in the study, with patients’ mean age was 30.5-year-old (range: 14- to 61-year-old), consisting of 19 males (67.9%) and 9 females (32.1%). In approximately 75% of the cases, the cause of CCF was a history of trauma. Patients with high flow CCFs were associated with the findings of cavernous sinus hyperdense and proptosis than patients with low flow. Patients who are presented with more than 1-year-long duration of symptoms were more likely to have more than 1 draining vein, compared to patients who are presented with < 1-year-long duration of symptoms.
 Conclusions: History of trauma, longer duration of symptoms, and the presence of a hyperdense cavernous lesion on head CT scan results require further angiographic study prior to endovascular intervention.

Ophthalmological presentation of carotid cavernous fistulas: case series and a paradigmatic case report

The purpose of this paper is to describe the clinical presentation of carotid cavernous fistulas (CCFs) managed in Hospital Egas Moniz between January 2010 and December 2020. Patients presenting with orbital congestive signs or symptoms with an ophthalmological evaluation and a diagnosis of CCF confirmed by digital subtraction angiography were included retrospectively. Carotid cavernous fistulas are rare and difficult to diagnose. Direct CCFs tend to have a more severe, acute onset presentation, while indirect CCFs are associated with a more insidious onset and chronic course. Anterior and inferior drainages are the most common in both direct and indirect CCF. Clinical presentation can be varied and nonspecific; however, patients commonly present with ophthalmological manifestations. All of our case series patients presented with ophthalmological complaints. The most frequently seen signs or symptoms were red eye (n = 8), increased intraocular pressure (IOP) (n = 8), and ophthalmoparesis with diplopia (n = 7).

Venous outflow-targeted coil embolization of direct carotid-cavernous fistulas.

Coil embolization is the mainstay treatment for carotid-cavernous fistulas (CCFs). However, few studies have reported entire occlusion of engorged veins to interrupt venous outflow. We report our experience with venous outflow-targeted coil embolization of direct CCFs. We retrospectively reviewed all the patients diagnosed with direct CCFs treated with venous outflow-targeted coil embolization between November 2013 and February 2020. Venous outflow-targeted coil embolization of the CCFs was performed as follows. First, transarterial stent-assisted coil embolization of CCFs was performed. If the venous outflow to the engorged veins persisted after transarterial stent-assisted coil embolization, entire occlusion of the engorged veins and additional coil packing within the cavernous sinus were performed to interrupt the venous outflow. Ten patients had undergone venous outflow-targeted coil embolization, 6 women (60%) and 4 men (40%). Transfemoral cerebral angiography showed high-flow, direct CCFs in all the patients. Venous outflow occurred through the superior ophthalmic vein (SOV) in all the patients and was completely interrupted by the entire occlusion of the engorged veins with fibered coils. Three patients (30%) had undergone additional treatment in a supplementary manner because of recurrent symptoms (chemosis in 1 patient, faint tinnitus in 2 patients) in the early postprocedural period (1 to 4 weeks). All the symptoms were resolved on follow-up. No additional recurrence was found during follow-up (1-75 months). No peri-procedural complications were encountered. Venous outflow-targeted coil embolization of CCFs would be a safe and effective treatment method.

PAINFUL OPHTHALMOPLEGIA IN CAROTID-CAVERNOUS FISTULA

Ophthalmoplegia is defined as a consequence of multiple cranial nerve paralysis innervated the extraocular muscles. The impairment of ophthalmic branch of trigeminal nerve will create a painful condition. Numerous underlying mechanism have been proposed related to painful ophthalmoplegia and carotid-cavernous fistula is one of the main causes with sight and life threatening outcome if left untreated. Carotid-cavernous fistula arises as an abnormal communication between carotid artery and cavernous sinus. Important signs and symptoms of carotid-cavernous fistula may include red eye, proptosis, painful ophthalmoplegia, headache and vision loss. Neuroimaging and angiography are mandatory in diagnosing the disease. Systematized approach and early recognition to the evaluation of carotid-cavernous fistula will lead to prompt management in avoiding morbidity and mortality in severe cases.

471 Prospective Comparison of CT and Digital Subtraction Angiography to Diagnose Penetrating Cerebrovascular Injuries: Preliminary Data

INTRODUCTION: Digital subtraction angiography (DSA) is the gold standard for detecting penetrating cerebrovascular injuries, but CT angiography (CTA) is often used. Few studies compare CTA and DSA for this indication and are retrospective, which indicate sensitivity of CTA is about 70%. METHODS: Prospective observational cohort study of all patients with penetrating head injuries at Harborview Medical Center, excluding patients with unsalvageable injuries. CTA of the head was performed immediately after presentation, followed by 6 vessel DSA within 48 hours. Sensitivity and specificity of CTA compared to DSA were then calculated. RESULTS: Enrollment is ongoing. 14 patients have undergone CTA and DSA of whom 7 have cerebrovascular injury. Of these CTA missed pathology seen on DSA in 4 cases, yielding sensitivity of 43%, all cases missing dural-arteriovenous or carotid-cavernous fistulae. In one case a small pseudoaneurysm was called on CTA that was not seen on DSA, yielding specificity of 86%. CONCLUSION: Early findings suggest that CTA is at least as insensitive for penetrating cerebrovascular injury as suggested by retrospective studies. This insensitvity is particularly relevant in cases of traumatic fistulae. More data are needed, and enrollment of subjects is ongoing at our center and at collaborating institutions.

Establishing a New Neurointerventional Facility in a Remote Area of a Low-Middle Income Country (LMIC): Initial Experience.

Background Timely performed Neurointervention procedures in patients with neurovascular disorders save them from mortality and lifelong morbidity, in addition to relieving the immense economic and social burden associated with these diseases. Materials and Methods We retrospectively reviewed data of neurointerventions performed in our hospital from November 2019 till March 2021. Patient age, sex, diagnosis, preoperative, and postoperative imaging findings were collected and analyzed. Types of procedures, success/failure, procedure-related and procedure-unrelated complications were noted and described. Results Total 161 procedures were done (diagnostic n = 89, therapeutic n = 72). Among the 72 cases of therapeutic procedures, angiographic success was noted in 60 cases, partial success was noted in 5 cases (RR grade 3 occlusion) and failure was noted in 7 cases [mechanical thrombectomy (n = 2), coiling (n = 1), flow diverter (n = 1), Caroticocavernous fistula (n = 1), cerebral Arteriovenous malformation (n = 2)]. Among therapeutic cases (n = 72), patient outcome was categorized as improved (with mRS 0-2 at discharge) in 64 cases (60 neurointerventions, 4 converted to surgery), morbidity in form of weakness was noted in 2 cases, mortality was noted in 8 cases. There were no hemorrhagic complications due to rupture or dissection. Ischemic complications were noted in form of thromboembolic complications in three cases and vessel occlusion (delayed MCA occlusion) in one case. Conclusion With recent efforts by medical associations and governments to provide access to these lifesaving, disability averting neuro-interventions, it’s important to recognize and define challenges in implementation of neuro-intervention services. In this article, we share our early experience in establishing a neurointervention facility in a backward region of a low–middle income country.

246 A Case Report on Bilateral Spontaneous Carotico-Cavernous Fistula with Literature Review

Abstract Background CCF is an abnormal vascular communication that allows blood to either directly or indirectly flow from the carotid arteries to the cavernous sinus. We present a rare case of spontaneous bilateral direct CCF. Coil embolization is a very effective treatment for CCF. Case report 86-year-old lady presented in ED with two weeks history of progressive painful, swollen right eye & drooping of eyelid with double vison in left eye. Patient also had a history of intermittent headache and had pulsatile tinnitus in right ear. There was no history of head or eye trauma. On examination, the lady had proptosis, chemosis and restricted movement in right eye, 3rd nerve palsy in left eye. Corrected vision +0.3 in right eye, +0.1 in left eye. Pupils were bilaterally sluggish, there was no relative afferent pupillary defect. CTA showed bilateral direct CCF along with dilated superior ophthalmic veins on both sides (L>R). No other associated or underlying pathologies were seen. She was started on oral Acetazolamide, Travoprost and Brimonidine topically. Patient was urgently referred to neurosurgery department and Coil embolization of her CCF was done successfully the following day. Eye casualty review was done day after her coil embolization. IOP pressure was decreased to normal limits -12 RE and 8 LE. Although her VA was slightly down compared to her preoperative visit, her other symptoms were improving. Six months later her vision has returned to normal. Conclusions Bilateral spontaneous CCF is a rare entity. Early diagnosis and treatment lead to successful outcomes. Neuro-radiological intervention is an effective treatment in acute setting.

Simultaneous transarterial and transvenous contrast injection to reveal the fistulous point in carotid cavernous fistula: illustrative case.

BACKGROUNDAccess of the cavernous sinus (CS) via venous route from the inferior petrosal sinus (IPS) can sometimes be challenging during the treatment of carotid cavernous fistulas (CCF), largely because of anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection.OBSERVATIONSA 58-year-old male was transferred to our university hospital center after suspected diagnosis of CCF at another hospital by head computerized tomography-angiogram. His symptoms included three weeks of right eye pain that was later complicated by redness, diplopia, and blurry vision. In a diagnostic angiogram, separate contrast injections from the arterial side via internal carotid artery (ICA) and from the venous side via IPS did not reveal a connection point. Injecting contrast simultaneously from both arterial and venous ends resulted in visualization of a connection point allowing entry into the CS.LESSONSTechnique of simultaneous contrast injection from ICA and internal jugular vein is comparatively simple and saves an operator prolonged time and complexity of approach. In our case, it revealed fistulous point allowing navigation and completing the coiling.

Radiation Dose and Fluoroscopy Time of Endovascular Coil Embolization in Patients with Carotid Cavernous Fistulas.

Carotid cavernous fistulas (CCFs) are abnormal connections between the cavernous sinus and the internal and/or external carotid artery. Endovascular therapy is the gold standard treatment. In the current retrospective single-center study we report detailed dosimetrics of all patients with CCFs treated by endovascular coil embolization between January 2012 and August 2021. Procedural and dosimetric data were compared between direct and indirect fistulas according to Barrow et al., and different DSA protocol groups. The local diagnostic reference level (DRL) was defined as the 3rd quartile of the dose distribution. In total, thirty patients met the study criteria. The local DRL was 376.2 Gy cm2. The procedural dose area product (DAP) (p = 0.03) and the number of implanted coils (p = 0.02) were significantly lower in direct fistulas. The median values for fluoroscopy time (FT) (p = 0.08) and number of DSA acquisitions (p = 0.84) were not significantly different between groups. There was a significantly positive correlation between DAP and FT (p = 0.003). The application of a dedicated low-dose protocol yielded a 32.6% DAP reduction. In conclusion, this study provides novel DRLs for endovascular CCF treatment using detachable coils. The data presented in this work might be used to establish new specific DRLs.

Frontal Arteriovenous Malformation Presenting as Painful Unilateral Conjunctiva Injection.

Case PresentationArteriovenous malformations (AVM) have a variety of clinically significant manifestations. This report details a patient who presented with unilateral conjunctiva injection, which was found to be due to an atypical manifestation of an AVM with a large draining vein mimicking carotid cavernous fistula.DiscussionWhile imaging for patients presenting with eye pain and unilateral conjunctiva injection is not always warranted, emergency physicians should keep their differential diagnosis broad and pursue additional workup when warning signs of more sinister pathology present.

Anatomical study of the internal carotid venous plexus: new findings with application to skull base surgery.

The venous plexus (internal carotid venous plexus) surrounding the petrous part of the internal carotid artery (ICAp) is said to be one drainage pathway of the cavernous sinus. These veins have many potential clinical implications including iatrogenic hemorrhage during surgical approaches to the skull base and carotid-cavernous fistulas. Because there are few morphological data about this venous plexus at the skull base, this descriptive/quantitative study was performed to elucidate its anatomy. Six latex-injected cadaveric heads (twelve sides) were dissected via a superior craniotomy approach in which the ICAp was exposed by drilling away the overlying bone. A venous plexus surrounding parts of the ICAp in all sides was documented along with the positions of its major tributaries and their connections. The veins were most concentrated near the junction of the ICAp and the cavernous part of the internal carotid artery, and usually along the medial and lateral sides of the ICAp. Tributaries included branches joining the basilar venous plexus posteriorly and branches joining the veins surrounding the foramen ovale anteriorly. Detailed knowledge of the anatomy of this venous plexus surrounding the ICAp is useful for interpreting imaging of the skull base and valuable for surgeons operating in this part of the cranium.

Onyx Embolization of an Indirect Carotid-Cavernous Fistula with Cortical Venous Reflux: Technical Note.

Indirect carotid-cavernous fistulas (iCCFs) are shunts between meningeal branches of the internal carotid and/or the external carotid arteries and the cavernous sinus. They account for 83% of all carotid-cavernous fistulas (CCFs). Symptomatic iCCFs and those with increased risk of hemorrhage should be treated. Transvenous endovascular treatment is the preferred treatment modality. However, in complex cases, a combination of transarterial and transvenous approaches (multimodal treatment) is required. A middle-aged woman presented with signs of increased intraocular pressure, blurry vision, diplopia, left proptosis, chemosis, conjunctival injection, ptosis, and cranial nerve VI palsy. Imaging confirmed the presence of a Barrow type D and Thomas type 4 iCCF with cortical venous reflux (CVR). The patient underwent transarterial and transvenous onyx embolization of the shunt, achieving a complete obliteration of the fistula. No complications occurred and the patient had a satisfactory postprocedural evolution. Multimodal onyx embolization is an effective option for the treatment of a complex symptomatic iCCF. If CVR is identified, these lesions should be promptly treated to prevent hemorrhage secondary to rupture.

Ophthalmological presentation of carotid cavernous fistulas: case series

AbstractPurposeTo describe the clinical presentation of carotid cavernous fistulas (CCFs) managed in Egas Moniz Hospital between January 2010 and September 2020.MethodsPatients presenting with orbital congestive signs and symptoms with a diagnosis of CCF confirmed by digital subtraction angiography and ophthalmological evaluation were included retrospectively. Clinical presentation and angiographic findings were collected, and a descriptive study was performed.ResultsTen patients were identified, 7 of which female, with an average age of 62.7 years old. All of our patients presented with ophthalmological complaints. The most frequently seen signs/symptoms were red eye (n = 8), increased intra‐ocular pressure (IOP) (n = 8) and ophthalmoparesis with diplopia (n = 7). Regarding the latter, 5 patients had paresis of the abducens nerve, 1 had a third nerve palsy and another had both. Proptosis and chemosis were observed in 5 and 4 patients, respectively. Tinnitus, fundus abnormalities and decreased visual acuity were reported by 3 patients. One patient presented with headache. In respect to the angiographic classification, 2 were direct and 6 indirect. One case was not classified and the other case refers to an intra‐clival Cognard type IV arteriovenous fistula that drains to the cavernous sinus and therefore closely resembling a CCF. Two patients were managed conservatively, while the remainder were submitted to endovascular procedures. After treatment, the most frequent persistent signs/symptoms were increased IOP (n = 7) and ophthalmoparesis with diplopia (n = 5).ConclusionsCCFs are rare and difficult to diagnose. Direct CCFs tend to have a more severe, acute onset presentation while indirect CCFs are associated with a more gradual onset and chronic course. In both, anterior and inferior drainages are the most common. Clinical presentation can be varied and nonspecific, however, patients commonly present with ophthalmological manifestations.

A rare case of nontraumatic bilateral carotid cavernous fistula Barrow type D – A case report

Carotid cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the normal carotid arterial system. We are presenting a very rare case of spontaneous nontraumatic bilateral Barrow type D CCF. A 41-year-old patient presented to our tertiary eye care center with a history of long-standing bilateral congested eyes. On imaging, the patient was diagnosed with spontaneous bilateral Barrow type D CCF. The patient improved significantly by treatment with carotid decompression exercises. It is recommended to consider the diagnosis of bilateral CCFs as a differential diagnosis in patients with long-standing history of congested eyes nonresponsive to conventional topical treatment.

Carotico-cavernous fistula - From the eye of an ophthalmologist

Carotid-cavernous fistulas (CCFs) are spontaneous or acquired abnormal connections between the cavernous sinus and the carotid arterial system. It can be a direct connection between the cavernous segment of the internal carotid artery and the cavernous sinus, or an indirect one between the cavernous sinus, and one or more meningeal branches of the internal carotid artery, external carotid artery, or both. Ophthalmologists are called to diagnose and manage the condition in cases that present with ocular features such as decreased vision, conjunctival chemosis, external ophthalmoplegia and proptosis. A high index of suspicion in a case without any history of trauma and collagen vascular disease is the key factor. Prompt diagnosis of intravascular malformations at initial presentation can prevent ophthalmological complications and vision loss. Conventional treatments include carotid ligation and embolization, with minimal significant morbidity or mortality. A team approach including neurosurgeons, emergency physicians and ophthalmologists is needed for the proper management of such patients. Ophthalmologists may be the primary attending physician; therefore, this review aims to help understand the diagnostic approach and possible modes of treatment with expected outcomes.

Delayed care in carotid-cavernous fistula due to the Covid-19 pandemic

Direct carotid-cavernous fistula is a high-flow communication between the internal carotid artery and the cavernous sinus that requires early transarterial embolization for its resolution. We report a case of a patient with a direct carotid-cavernous fistula who subsequently developed a central retinal vein thrombosis due to a delay in treatment related to the health collapse experienced in the first months of the Covid-19 pandemic in Spain.

Management of neurovascular emergencies with ophthalmic manifestations.

Patients with neurovascular disorders sometimes approach the ophthalmologists with mild ophthalmic clinical features such as conjunctival congestion, slowly progressive proptosis, lateral rectus palsies and at other times with ophthalmic emergencies like sudden increase in proptosis, ophthalmoplegia, diplopia, and ptosis before the onset of neurological manifestations which may be life-threatening if not detected in time. The aim of this article is to focus on ophthalmic manifestations of neurovascular emergencies and role of ophthalmologists in its management. In this communication, to make the ophthalmologist aware of clinical presentations, the imaging modality of choice, diagnostic features, medical and interventional treatments. We have searched PubMed, Web of Science, Google Scholar and reviewed some of the commonly encountered neurovascular emergencies with ocular manifestations such as carotid-cavernous fistula, cerebral venous sinus thrombosis, cerebral artery aneurysms, arterio-venous malformations.

Balloon-Assisted Coil and Liquid Embolizing System Repair of Barrow's Type A Carotico-Cavernous Fistula.

Balloon-Assisted Coil and Liquid Embolizing System Repair of Barrow's Type A Carotico-Cavernous Fistula.

Delayed diagnosis of traumatic internal carotid-cavernous sinus fistula due to multiple trauma

Delayed diagnosis of traumatic internal carotid-cavernous sinus fistula due to multiple trauma