Direct Carotid-cavernous Sinus Fistulas Research Articles

Clinical Risk Score for Prediction of Urgency in Carotid Cavernous Sinus Fistulas.

To develop a clinical risk score for the prediction of urgency in patients with carotid cavernous sinus fistulas (CCFs) and test for the discriminative ability of the diagnostic prediction. The medical charts of 60 patients with CCFs were retrospectively reviewed. The clinical characteristics of direct and dural CCFs were analyzed by logistic regression. The clinical risk score was developed from the coefficient in the multivariable regression model and used to predict direct CCFs which were more urgent than the dural type. The score prediction was reported as an area under the receiver operating characteristic (AuROC) curve and 95% confidence interval (95% CI). In a univariable analysis, the clinical characteristics which increased the risk of direct CCFs were age, gender, trauma, underlying diseases, visual acuity (VA) at presentation, bruit, chemosis, and dilated retinal vessels. However, in multivariable analysis, the significant predictors were limited to age, trauma, bruit, underlying diseases and logMAR VA. Regression coefficient of each predictor was converted to a risk score and summation of scores from these predictors for each patient was calculated. The total risk score predicted the urgent direct CCFs correctly with AuROC of 97.77% (95% CI; 93.57, 100). The clinical risk score for the prediction of urgent direct CCFs has been developed and used in the patients with CCFs in our setting. The discriminative ability of the score prediction is high. This simple clinical risk score may help clinicians suspect direct CCFs and urgently refer the patients to have prompt angiography and treatment.

Direct and Dural Carotid Cavernous Sinus Fistulas: Comparison of Clinical Characteristics.

To compare the clinical characteristics of patients with direct and dural carotid cavernous sinus fistulas (CCFs). The medical records of 60 patients diagnosed with CCFs were retrospectively reviewed. The collected data included demographic characteristics, clinical findings, and ocular manifestation. The clinical characteristics of the direct and the dural CCFs were compared on head-to-head basis. Logistic regression analysis was used to demonstrate the direction and magnitude of the difference and reported as odds ratio with its 95% confidence interval. There were 28 patients (46.67%) with direct CCFs, and 32 patients (53.33%) with dural CCFs. Patients with direct CCF were mostly male (p=0.023), younger age (p<0.001), had history of trauma (p<0.001), and more visual impairment at presentation (p=0.025), when compared to those with dural CCFs. In addition, patients with direct CCF had significantly more chemosis (p=0.005), proptosis (p=0.042), bruit (p<0.001) and dilated retinal vessels (p=0.008) than those with dural CCF. Thirty patients (50%) had increased intraocular pressure (IOP). Mean IOP of the affected eyes was significantly higher than the unaffected eyes (p<0.0001). In patients with normal IOP, mean IOP of the affected eyes was also higher than the unaffected eyes (p=0.0027). Patients with direct CCF were younger age, associated with trauma, and more visual impairment at presentation. Chemosis, proptosis, bruit and dilated retinal vessels were detected more in the direct CCF than the dural CCF. Despite normal IOP, affected eyes had significantly higher IOP than the unaffected eyes. Information on these clinical characteristics may be helpful in discrimination of the direct type, which is more urgent for further investigation and treatment.

Clinical Profile and Management Outcomes among Patients with Carotid-Cavernous Fistula.

A carotid-cavernous sinus fistula (CCF) is an abnormal communication between the internal carotid artery and/or the external carotid artery and the cavernous sinus. There is a paucity of information on the ophthalmic outcomes of endovascular treatment for CCF in the Philippines. This study aimed to describe the clinical experience of CCF in our institution in order to further our understanding of the disease. This study described the demographic profile, risk factors, and clinical features of patients with CCF, and compared the data of patients according to the type of CCF. The study discussed the changes in clinical features over time in CCF patients who chose not to undergo endovascular treatment. The study also discussed the clinical outcomes of CCF patients who underwent endovascular treatment and compared the clinical outcomes to CCF patients who did not undergo endovascular treatment. A retrospective cohort study design was performed using a medical record review of patients clinically diagnosed with CCF from January 2011 to June 2019. One hundred twenty medical records of patients diagnosed with CCF were included. Based on angiographic findings, patients were grouped according to type of CCF, with 86 patients in Group 1 or Direct CCF, 23 patients in Group 2 or Indirect CCF, and 11 patients in Group 3 or Mixed type of CCF. The patients were also grouped according to treatment, with 109 patients in Group A, or patients who did not undergo endovascular treatment, and 11 patients in Group B, or patients who underwent endovascular treatment. There was a male predominance in CCF, most occurring in the age range of 26 to 35 years. Risk factors for CCF were trauma and hypertension. Clinical features included the presence of blurring of vision, proptosis, corkscrewing of conjunctival vessels, extraocular movement limitation, diplopia, audible bruit, elevated intraocular pressure, and pulsation. Findings on Computed Tomography scan included dilated superior ophthalmic vein, proptosis, and enlarged extraocular muscles. Direct CCF (Group 1) occurred mostly in males, with mean age of 39.1 years, and with trauma as the major risk factor. Indirect CCF (Group 2) occurred mostly in females, with mean age of 52.1 years, and with hypertension as the major risk factor. Regardless of the type of CCF, patients who did not undergo endovascular treatment can exhibit spontaneous improvement or worsening of clinical features. Patients who underwent endovascular treatment generally had favorable clinical outcomes, manifesting as either improvement or no worsening of features. There were minimal ophthalmic complications associated with treatment. Endovascular treatment is safe and effective in the improvement of visual acuity, corkscrewing of conjunctival vessels, amount of proptosis, extraocular movement limitation, diplopia, and presence of audible bruit.

Advantage of Balloon Guide Catheter During Endovascular Treatment of Direct Carotid-Cavernous Sinus Fistula: Technical Note and Report of 2 Cases

As previous studies reported, the balloon guide catheter is useful for identifying the fistula point during diagnosis of direct carotid-cavernous sinus fistula (d-CCF). We demonstrate an additional advantage of the balloon guide catheter during intraarterial endovascular treatment of d-CCF. Two cases of d-CCF are presented in this report. A balloon guide catheter is used to help achieve successful coil embolization of the fistula in both cases. Microcatheter positioning into the fistulous point can be easier after balloon inflation. Balloon inflation can help with coil deployment. Using a balloon guiding catheter can reduce internal carotid artery flow near the fistula point at the cavernous segment of the internal carotid artery. As a result, better identification of the fistula point can be made, which allows easier placement of the microcatheter into the fistula point and more stable coil deployment.

Spontaneous direct carotid-cavernous sinus fistula secondary to a persistent primitive trigeminal artery treated by trans-venous coil embolisation.

A healthy 51-year-old female presented with a spontaneous direct carotid-cavernous sinus fistula associated with a persistent primitive trigeminal artery. She had no history of connective tissue or cerebrovascular disorders or significant head trauma. This is a rare lesion with only 18 previously reported cases. It had similar clinical presentation and imaging appearance to a high-flow direct carotid-cavernous fistula and was uncovered after successful trans-venous coil embolisation of the fistula. It therefore needs to be considered in cases of direct carotid-cavernous fistula without history of trauma. Knowledge of types of persistent primitive trigeminal artery is also important for their critical treatment implications.

Flow Diverters as Useful Adjunct to Traditional Endovascular Techniques in Treatment of Direct Carotid-Cavernous Fistulas.

Direct carotid-cavernous sinus fistulas (CCFs) are high-flow arteriovenous shunts that are typically the result of a severe head injury. The endovascular treatment of these lesions includes the use of detachable balloons, coils, liquid embolic agents, and covered stents. To minimize the chance of treatment failure and subsequent complications, endoluminal reconstruction using a flow-diverting stent may be added to the treatment construct. We present 3 cases and review the existing literature. Three patients with direct traumatic CCFs were treated with either coils, coils and Onyx, or a detachable balloon, followed by placement of a flow-diverting stent for endoluminal reconstruction. All 3 cases had complete angiographic occlusion of the CCFs and recovered clinically. No complications were observed. We believe that endovascular coil or balloon occlusion of the fistula from either a transvenous or transarterial approach followed by flow diversion may be an appropriate treatment for direct CCFs. This addition of a flow diverter may facilitate endothelialization of the injury to the internal carotid artery.

Direct Carotid-Cavernous Sinus Fistula Following Closed Head Injury

A case of direct carotid-cavernous sinus fistula (CCF) after closed head injury is presented. A 22-year-old male presented to the emergency department of Shohada Tajrish Hospital with the chief complaint of blurred vision and pulsatile retro-orbital headache. The patient had closed head injury due to car accident 2 month ago with lower limb fracture. After a 2-week symptom-free period, he developed scalp and right facial tingling, along with pulsatile retro-orbital headache and vision problems. His vital signs were within normal limits, but on primary evaluation the patient orbital and carotid bruits could be recognized. Computed tomography (CT) scan and magnetic resonance imaging (MRI) suggested the carotid-cavernous sinus fistula, which was confirmed by brain angiographic imaging findings. Carotid-cavernous sinus fistula is an uncommon condition that is usually caused by head trauma but can advance spontaneously in about one fourth of patients with CCF. The connection between the carotid artery and cavernous sinus leads to increased pressure in the cavernous sinus and compression of its contents, and finally advances the clinical symptoms and signs seen. Diagnosis is based on clinical evaluation and neuroimaging techniques. The target of management is to decrease the pressure within the cavernous sinus, which results in gradual recovery of symptoms.

Traumatic Carotid-Cavernous Sinus Fistula in a Patient with Facial Bone Fractures.

Carotid-cavernous sinus fistulas (CCFs) are abnormal connections between the cavernous sinus and the carotid arterial system (the internal carotid artery, external carotid artery, or both). CCFs may be classified as spontaneous or acquired and as direct (high blood flow) or dural (low blood flow) [[1]]. Direct CCFs represent 70% to 90% of all CCFs, and mostly result from head trauma, especially basal skull fractures [[2]]. Patients with CCFs may present with signs and symptoms such as conjunctival chemosis, decreased vision, proptosis, diplopia, orbital pain, audible bruits, headache, and blindness [[2] [3]]. In this report, we present the case of a 49-year-old man with a CCF and ophthalmic symptoms, resulting from a left zygomaticomaxillary complex fracture.

E-033 Treatment of Carotid-Cavernous Fistulas with a Double Lumen Balloon

IntroductionTreatment of direct high-flow carotid-cavernous sinus fistulas (CCF) can be challenging. Treatment of CCFs with dual lumen balloons has not been described.PurposeTo describe two cases in which the CCF was...

Clinical features of carotid-cavernous sinus fistulas in 23 patients

To analyze the clinical features of carotid-cavernous sinus fistulas (CCFs). The medical records of 23 patients with CCFs, which was confirmed by conventional cerebral angiography, in Peking Union Medical College Hospital from January 1990 to October 2012 were retrospectively analyzed. Data including patient characteristics, clinical features on ophthalmic examination, neurological assessment, and imaging study were collected.The differences between the direct and the indirect CCFs were compared, and the reasons for misdiagnoses were analyzed. Most patients were presented with ocular symptoms (78.3%). The most common signs were conjunctival injection or chemosis (78.3%), proptosis (69.6%), and ocular motor palsies (56.5%). There were 13 (56.5%) direct CCFs and 1 0(43.5%) indirect CCFs, and a history of encephalic trauma was more frequently reported among the former (61.5%) than the latter (10.0%); also, intracranial vascular murmur was more prevalent in patients with direct CCFs (69.2%vs.20.0%). Nine patients were misdiagnosed as other ocular diseases. Nonspecific clinical symptoms and signs such as chemosis, elevated intraocular pressure, and diplopia were the common causes of the misdiagnoses. Misdiagnosis of CCFs remains common due to its diverse clinical manifestations.CCFs should be suspected in patients with refractory red eyes, intraocular pressure elevation, proptosis and/or ophthalmoplegia, and a detailed history-taking, careful physical examination, and adequate imaging may minimize the misdiagnosis.

Endovascular Management of Direct Carotid-Cavernous Sinus Fistulas

To evaluate the single-centre experience with endovascular management of direct carotid-cavernous sinus fistulas (DCCF). Between November 2008 and November 2010, a total of 14 patients (11 males) with direct carotid-cavernous sinus fistula underwent 16 transarterial treatment sessions. The patient files and angiograms were analysed retrospectively. Clinical signs and symptoms included exophthalmos [n=12, (85.7%)], pulsatile tinnitus [n=9, (64.3%)], cranial nerve III or VI palsy [n=2, (14.3%)], and impaired vision [n=1, (7.1%)]. Angiography revealed in addition cortical drainage in five patients (35.7%). Transarterial embolization was performed using detachable balloon in nine sessions (56.2%), detachable coils in three sessions (18.8%) and a combination with Onyx in four sessions (25%). Complete interruption of the arteriovenous shunt was achieved in all patients. There was a tendency for ocular pressure-related symptoms to resolve rapidly, while cranial nerve palsy and diplopia improved slowly (7.1%) or did not change (7.1%). The patient with visual impairment recovered within the first two weeks after endovascular treatment. After complete interruption of the arteriovenous shunt, two (12.5%) recurrences were observed in balloon treatment and retreatment was given. Transarterial management is a highly efficient and safe treatment in DCCFs. In the majority of patients a significant and permanent improvement in clinical signs and symptoms can be achieved.

Management of direct carotid-cavernous sinus fistulas with the use of ethylene-vinyl alcohol (Onyx) only: preliminary results

So-called direct carotid-cavernous fistulas (CCFs) are commonly treated by detachable balloons or coils to occlude the shunt while sparing the carotid artery. Liquid embolic agents have been rarely used, and in particular, to the authors' knowledge, the use of Onyx as the sole agent has never been reported in an indexed publication. The authors describe a case series of 5 patients with posttraumatic CCF in whom embolization with Onyx was prospectively used as the sole strategy of management. Complete occlusion was obtained at the end of the procedure in 4 cases, and the lesion in the remaining patient subsequently occluded at the 6-month follow-up evaluation. As endovascular techniques for treatment of direct CCFs continue to evolve, this novel approach with Onyx as the sole embolic material seems promising in treating these lesions.

Hemispheric Laminar Necrosis as a Complication of Traumatic Carotid-Cavernous Sinus Fistula -Case Report-

A 43-year-old woman presented with a very rare case of hemispheric laminar necrosis as a complication of traumatic carotid-cavernous sinus fistula (CCF). The patient suffered head injury and extensive burns following a car accident. Oral intubation was performed under sedation. When sedation was discontinued 17 days after injury, the patient demonstrated left hemiparesis. Magnetic resonance imaging showed laminar necrosis affecting the right cerebral hemisphere. Angiography revealed a right high-flow direct CCF. Transarterial embolization of the fistula using a detachable balloon achieved complete occlusion of the fistula. However, the left hemiparesis persisted following this intervention. Traumatic CCF may be missed in patients with disturbed consciousness, so clinicians should not overlook possibility of the triad of symptoms of CCF in patients with head injury.

Air in the carotid canal as a predictor of distal internal carotid artery laceration

The authors describe a 25-year old patient with blunt trauma-induced bilateral, distal segment internal carotid artery (ICA) lacerations, resulting in a left-sided direct carotid-cavernous sinus fistula (CCF) and presenting with massive oronasal bleeding. The combination of severe oronasal bleeding, with air in the carotid canal should alarm the treating physician to the presence of a distal internal carotid artery laceration.

Fistule carotido-caverneuse traumatique: À propos d’un cas

The diagnosis of carotid-cavernous sinus fistula is based on clinical findings and must be confirmed and detailed by CT scan and arteriography. If the treatment, based on embolization, is not undertaken in the emergency room, visual complications or even death may result. We give an example of a direct post-traumatic carotid-cavernous sinus fistula, stressing its clinical characteristics (ophthalmoplegia) and treatment: the advantages of arteriography and of embolization methods (most often by detachable balloon or coils, through arteries or veins).

CT and MR Angiography for Pre-Embolization Evaluation in Direct Carotid Cavernous Sinus Fistula

CT and MR Angiography for Pre-Embolization Evaluation in Direct Carotid Cavernous Sinus Fistula

Cavernous sinus fistulas: carotid cavernous fistulas and dural arteriovenous malformations.

Direct and indirect carotid cavernous sinus fistulas are uncommon vascular anomalies that result in increased pressure in the cavernous sinus. The subsequent changes in blood flow lead to orbital venous congestion, cranial neuropathies, and glaucoma. The following review summarizes knowledge of the clinical features, natural history, diagnostic testing, and therapy for carotid cavernous sinus fistulas.

A Red Eye and Then a Really Red Eye

A 90-year-old woman presented with a 4-week history of a presumed infectious conjunctivitis resistant to topical antibiotic medications. Examination revealed tortuous, dilated conjunctival vessels in the right eye, retinal hemorrhages, and an orbital bruit suggestive of a carotid-cavernous sinus fistula (CCF). While awaiting a magnetic resonance imaging study, she returned to the clinic the next day with a painful, swollen right eye and an intraocular pressure of 69 mm Hg. A cerebral arteriogram confirmed a direct CCF. Because of the tortuosity of the systemic vascular anatomy, a right carotid artery cut-down with balloon occlusion was performed with successful closure of the fistula and prompt resolution of the orbital congestion. This case illustrates the spectrum of subtle to conspicuous ocular manifestations that can be seen in patients with CCF and its potential to present as an emergency. CCF should be included in the differential diagnosis of an “atypical” red eye. Recognition of arteriolized conjunctival vessels and auscultation of an orbital bruit raises the possibility of a CCF, requiring prompt diagnostic studies.

Left Dural to Right Cavernous Sinus Fistula A Case Report

Direct carotid-cavernous sinus fistulas that present with signs and symptoms contralateral to the arterial supply of the fistulas are not uncommon. We present a thoroughly documented case of a dural-cavernous sinus fistula with symptoms exclusively contralateral to the arterial source, a rarer entity. The patient presented with a red, proptotic right eye and a history of transient horizontal diplopia and a "feeling of fullness" in that eye. Magnetic resonance imaging (MRI) of the brain and orbits performed at another hospital had shown no abnormalities. Carotid angiography performed on the right side was normal; carotid angiography performed on the left side showed a dural-cavernous sinus fistula, with shunting from branches of the left external carotid artery directly to the right cavernous sinus. Orbital duplex color-flow sonography showed reverse flow in a dilated right superior ophthalmic vein. This unusual manifestation of a dural-cavernous sinus fistula offers insight into the pathophysiology of arteriovenous fistulas involving the cavernous sinus, and is a reminder that bilateral injections are required when performing carotid angiography to characterize these disorders.

Traumatic carotid-cavernous sinus fistula associated with an intradural pseudoaneurysm: A case report

A case of traumatic carotid-cavernous sinus fistula (CCF) associated with an intradural pseudoaneurysm is reported. A 42-year-old man developed traumatic CCF after severe head trauma. Cerebral angiography demonstrated a direct CCF associated with an intradural pseudoaneurysm at the C2 portion. Transarterial balloon embolization of the CCF caused severe subarachnoid hemorrhage. A CCF with an intradural pseudoaneurysm is life-threatening and requires emergency treatment. However, balloon occlusion in such cases is contraindicated because of possible rupture of a pseudoaneurysm. Trapping or a direct surgical approach is the treatment of choice.