Indirect Carotid Cavernous Fistula Research Articles

Commentary: Surgical Ligation of an Indirect Carotid-Cavernous Fistula With Exclusive Retrograde Cortical Venous Drainage: 2-Dimensional Operative Video.

Commentary: Surgical Ligation of an Indirect Carotid-Cavernous Fistula With Exclusive Retrograde Cortical Venous Drainage: 2-Dimensional Operative Video.

Long-term outcome of endovascular treatment for indirect carotid-cavernous fistulas.

Endovascular treatment (EVT) is the primary approach used to treat indirect carotid-cavernous fistulas (CCFs). In this study, the authors evaluated the immediate and long-term efficacy and safety of different endovascular techniques for indirect CCFs. The databases of two endovascular centers were retrospectively reviewed to collect the patients with indirect CCFs treated using endovascular techniques between 2013 and 2023. Demographics, clinical presentation, CCF features, EVT characteristics, and clinical and radiological outcomes were evaluated and analyzed. The analysis was performed to compare the clinical and radiological data between different endovascular approaches and different embolic materials. Ninety-eight patients were included in the study. EVT was successful in 95 patients (96.9%). Immediate complete obliteration of the CCF was achieved in 93.9% of patients, with 98% undergoing embolization with liquid embolic agents (LEAs) and 95.6% undergoing coiling alone. Complete CCF obliteration was higher in the transvenous than in the transarterial approach (94.3% vs 75%, p = 0.010). At ≥ 6 months follow-up, complete CCF obliteration was achieved in all patients (100%). The rate of procedure-related complications was higher following LEAs than with coiling alone (32.0% vs 15.6%). New cranial nerve (CN) palsy was diagnosed in 26.0% and 2.2% after embolization with LEAs and coiling alone, respectively (p = 0.001), with complete CN palsy recovery in 78.6%. Procedure-related intracranial hemorrhage occurred in 3 patients (3.1%). Two patients experienced an ischemic stroke following Onyx migration into the internal carotid artery. Ocular symptoms improved in 93% (83/89) of the patients who were followed. In this study, complete obliteration of an indirect CCF was achieved in more than 90% of patients. Despite the occurrence of some new postprocedural ocular CN palsy, ocular symptoms improved in most patients in long-term follow-up. The transvenous approach was the most effective method for treating the indirect CCF. Coiling was safer than LEAs for the embolization of the indirect CCF.

Comparison of the transarterial, transvenous, and superior ophthalmic vein approaches in the treatment of indirect carotid-cavernous fistulas.

Indirect carotid-cavernous fistulas (CCFs) are abnormal arteriovenous shunting lesions with a highly variable clinical presentation that depends on the drainage pattern. Based on venous drainage, treatment can be either transarterial (TA) or transvenous (TV). The aim of this study was to compare the outcomes of indirect CCF embolization via the TA, TV, and direct superior ophthalmic vein (SOV) approaches. The authors conducted a retrospective analysis of 74 patients admitted to their institution from 2010 to 2023 with the diagnosis of 77 indirect CCFs as confirmed on digital subtraction angiography. A total of 74 patients with 77 indirect CCFs were included in this study. Embolization was performed via the TA approach in 4 cases, the TV approach in 50 cases, and the SOV in 23 cases. At the end of the procedure, complete occlusion was achieved in 76 (98.7%) cases. The rate of complete occlusion at the end of the procedure and at last radiological follow-up was significantly higher in the SOV and TV cohorts than in the TA cohort. The rate of recurrence was highest in the TA cohort (25% for TA vs 5.3% for TV vs 0% for SOV, p = 0.68). The rate of immediate complete occlusion was higher in the TV and SOV cohorts than in the TA cohort while the rate of complete occlusion at final follow-up was highest in the SOV cohort. The SOV approach was significantly associated with higher rates of postoperative complications. Indirect CCFs require careful examination of the fistulous point and the venous drainage to provide the most effective patient-tailored approach.

Surgical Ligation of an Indirect Carotid-Cavernous Fistula With Exclusive Retrograde Cortical Venous Drainage: 2-Dimensional Operative Video.

Indirect carotid-cavernous fistulas (CCFs) are abnormal connections between the cavernous sinus and branches of the internal and external carotid arteries. Indirect CCFs with progressive cortical venous drainage require obliteration to prevent neurological decline secondary to their rupture or progression. While indirect CCFs are often treated with transvenous embolization of their venous outflow through the inferior or superior petrosal sinuses, facial vein, or superior ophthalmic vein, CCFs failing previous embolization may be best treated with surgical ligation. Here we present the case of a 30-year old woman who, 3 years before presentation to our institution, presented with transient monocular blindness to an outside institution. Catheter angiography revealed a CCF without cortical venous drainage which was partially embolized with coils. Catheter angiography at the 1-year follow-up revealed CCF progression characterized by cortical venous drainage into a right cortical vein, basal temporal vein, and the vein of Labbé. The lesion was treated with partial onyx embolization. Two years later, further evaluation at our institution demonstrated cortical venous ectasia-confirming CCF progression. Though asymptomatic, the risk of neurological decline secondary to progression or rupture of the lesion was high given the progressive cortical venous drainage, and treatment was indicated. As the lesion failed endovascular therapy twice, the patient underwent a right pterional craniotomy for surgical disconnection of the CCF's main draining vein and other fistulous connections. The patient had an uneventful recovery, and postoperative catheter angiography suggested complete obliteration of the lesion. Appropriate consent was obtained for the publication of the cadaver's image. The patient consented to the procedure and video recording.

A Continuous Red Eye: Case Report of Indirect Carotid Cavernous Fistula

Abstract
 Introduction : Carotid cavernous fistula (CCF) is a type of arteriovenous shunt in the cavernous sinus. Indirect CCF symptoms are not typical that can outwit us. Ocular manifestations occur because of venous and arterial stasis around the eye and orbit. The aim of this report is to increase awareness of the existence of other causes if there is no improvement after treatment.
 Case Illustration : A 59-year-old male presented with prolong conjunctival hyperemia on both eyes for two months that been diagnosed and treated as conjunctivitis. The ophthalmologic examination showed dilated episcleral vessels on both eyes with no evidence of infection and inflammation, this became a suspicion about the existence of a suppression from retro orbital region. The magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) brain examination were performed anda right CCF was diagnosed. The patient was referred to interventional neurology, digital subtraction angiography (DSA) examination showed a fistula in the right cavernous sinus and embolization was conducted.
 Discussion : The patient categorized as spontaneous, low flow, indirect CCF Barrow type D. On this type of CCF conjunctival injection is often the most prominent feature, and patients are commonly treated for other conditions, such as conjunctivitis, before a correct diagnosis is made.
 Conclusion : Carotid cavernous fistula can be characterized by the insidious onset of symptoms, diagnosis is based on the angiographic examination. When a sign suggestive of orbital or cavernous sinus pathology is present, a more thorough examination is crucial. Early diagnosis and appropriate management are essential to avoid vision and life threatening complications.

Off-label use of large diameter Concerto fibered coils through a 0.017 inch microcatheter for transvenous embolization of indirect carotid-cavernous fistulas: two case reports

BackgroundA carotid-cavernous fistula is an abnormal communication between the arteries and veins within the cavernous sinus. While conservative management may be prudent in low risk cases, many patients require intervention and endovascular embolization has evolved as the preferred method of treatment. Embolization can be performed via either the transarterial or transvenous approach. One major challenge of the transvenous approach is the complex and variable compartmentation of the cavernous sinus, which often requires the use of low profile microcatheters to navigate and reach the fistulous point. Fibered coils are also preferred when performing transvenous embolization of carotid-cavernous fistula, as they are of higher thrombogenicity and allow for faster occlusion of the fistula. However, most low profile (0.017-inch) microcatheters are not able to deploy fibered coils based on the manufacturer’s instructions.Case presentationWe present two successful cases of off-label use of Medtronic Concerto fibered coils via a 0.017-inch microcatheter during transvenous embolization of carotid-cavernous fistula in a 60-year-old and an 80-year-old Chinese female, respectively.ConclusionOur case series highlight the possibility of deploying large diameter (up to 10 mm) Concerto fibered coils through a low profile (0.017-inch) microcatheter in an off-label manner for transvenous embolization of indirect carotid-cavernous fistula.

Indications for alternative endovascular techniques in carotid-cavernous fistulas: A 20-year single-center experience.

While coiling is considered the standard treatment for carotid-cavernous fistulas (CCFs), studies demonstrating excellent results using new materials, especially flow diverter (FD) stents and liquid embolisates, are becoming more frequent. The indications and effectiveness of these alternative endovascular techniques remain unclear. A total of 22 direct and 20 indirect CCFs were included in the study. These were further subdivided based on the embolic material used: coils versus FD stents for direct and coils versus liquid embolisates for indirect CCFs. The subgroups were subjected to statistical analysis. An angiographic cure was achieved in 88% of all CCFs, 93% of patients' experienced clinical improvement or remained stable. Direct CCFs were treated with coiling (41%) or with both coils and FD stents (55%). One (4%) patient with a direct CCF was treated with FD stent alone. Statistical analysis comparing these subgroups revealed a significantly higher complete occlusion rate immediately after treatment in the coiling subgroup (67% vs. 23%, p = 0.0409). The occlusion rates at the last follow-up were similar (89% vs. 85%). Indirect CCFs were treated with coiling (35%) or liquid embolisates (65%). All three periprocedural ischemic complications were recorded within the liquid subgroup, resulting in a significantly higher clinical deterioration rate (p = 0.0333). FD stents in direct and liquid embolisates in indirect fistulas did not demonstrate better angiographic or clinical outcomes compared to convetional coiling. Liquid agents carried a higher risk of ischemic complications. Alternative embolization materials should be reserved for CCFs that cannot be treated with simple coiling.

Abstract 162: Indirect Carotid Cavernous Fistula with Oculomotor Nerve Palsy Secondary to Trauma

Introduction Intriguing and uncommon, we present a fascinating case of carotid‐cavernous fistula (CCF) following ocular trauma. Delving into medical nuances and outcomes, this reported case offers valuable insights for clinicians and researchers in the field of ophthalmology and interventional Neurology. Methods An elderly patient presented to the emergency department with diplopia and left eyelid ptosis two weeks after left ocular trauma. The patient had exotropia and hypotropia with restricted movement in all directions but mostly during adduction and infraduction which led to the diagnosis of oculomotor nerve palsy. Computer Tomography (CT) head was obtained which showed mild left proptosis with the prominence of the optic nerve sheath complex, CT angiography revealed asymmetric prominence of the left ophthalmic veins and enlarged left cavernous sinus with outward convex borders. CT face and mandible with IV contrast did not show any bony deformity. The patient underwent cerebral angiography that showed an indirect type 4 cavernous‐carotid fistula. Results A precise incidence of CCF fistula has not been reported so far in the literature but it is estimated to be present in 0.2 % of patients presenting with traumatic brain injury with an increased incidence of 4 % with basilar skull fractures. They can occur spontaneously or following closed skull injury, skull base fractures, or iatrogenically after craniotomies, endoscopic transsphenoidal or sinus surgery, and endovascular procedures. They can be classified based on angiographic arterial architecture (direct or indirect), hemodynamics (high flow or low flow), and etiology (spontaneous or traumatic). Type A are direct fistulas, whereas types B, C, and D are indirect fistulas. Direct CCFs often present with pulsatile exophthalmos, orbital bruit, chemosis, diplopia, ocular redness, orbital pain, swelling, swishing or buzzing sounds, headache, or vision loss. Indirect low‐flow CCFs may be asymptomatic and insidious in onset and mostly present with chemosis and conjunctival injection. Conclusion Indirect carotid‐cavernous fistula rarely occurs secondary to a head trauma without any bony deformity and it's even rare to have an oculomotor nerve palsy on presentation, it should be considered as an etiology when evaluating patients for ocular nerve palsies.

High-Flow Indirect Carotid-Cavernous Fistula with Transarterial and Transvenous Endovascular Treatment

Male, 39 years old, with a progressive headache for seven months, progressive right exophthalmos, right chemosis and conjunctival edema, pulsatile tinnitus and carotid bruit in the right frontotemporal region. Cerebral magnetic nuclear angioresonance showed multiple anomalous vascular structures near the sphenoparietal sinus, pterygoid plexus, superior and inferior orbital fissures, all on the right, with swelling of the basilar plexus. A diagnostic cerebral and cervical arteriography was performed, which showed a high-output indirect Carotid-Cavernous Fistula (CCF), nourished mainly by multiple dysplastic dural branches originating from the mandibular and pterygopalatine segments of the internal maxillary artery and secondarily by the inferolateral trunk. There was hypertensive venous drainage anteriorly through the ecstatic superior and inferior ophthalmic veins, corresponding angular and facial veins, and posteriorly to both cavernous sinuses, basilar plexus, superior petrosal sinuses, and internal jugular veins (Type D, Barrow Classification). The patient underwent arterial embolization with hystoacril and lipiodol in branches of the right internal maxillary artery and venous embolization with platinum micro coils with occlusion of the fistula. He evolved well with the improvement of symptoms, being discharged from the hospital and scheduled for outpatient follow-up.

Efficiency of endovascular management with a combination of Onyx and coils for direct and indirect carotid cavernous fistula treatment: Experience of a single center

BackgroundTo evaluate the safety and efficacy of endovascular treatment with a combination of Onyx and coils for carotid cavernous fistulas (CCFs), and to characterize the factors associated with clinical and angiographic outcomes for direct and indirect CCFs. MethodsThis retrospective study included 31 patients with CCF treated with an endovascular procedure between December 2017 and March 2022. ResultsDirect and indirect CCFs were found in 14 (45.2%) and 17 (54.8%) cases, respectively. Direct CCFs included eleven traumatic carotid cavernous fistulas. The most common symptom on admission was chemosis, which was seen in 17 (54.8%) patients. Eight (25.7%) cases were treated by the transarterial approach. Fourteen (45.2%) cases were treated using the femoral vein-inferior petrosal sinus approach. Seven (22.6%) were treated by direct puncture of the superior ophthalmic vein. Two (6.5%) were treated by the femoral vein-facial vein approach. Immediate complete occlusion and follow-up rates were 93.5% and 96.7%, respectively. Twenty-nine (96.7%) patients experienced an improvement in their symptoms at clinical follow-up. Chemosis was significantly improved or resolved in 15 patients. Ophthalmoplegia was improved or resolved in 10 patients. Visual impairment was improved in 6 patients. Proptosis was improved or resolved in 5 patients. One case (3.2%) experienced procedure-related complication presented with transient oculomotor nerve palsy. In univariate subgroup analysis, use of balloon, treatment approach, and history of head trauma were significantly different between the direct and indirect CCF groups. ConclusionsEndovascular treatment with a combination of Onyx and coils is a safe and effective therapy for CCFs. In this study, the transarterial approach was a favorable option for embolization of direct CCFs. In contrast, the transvenous approach may be the first choice of treatment for indirect CCFs.

Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication?

Flow diversion (FD) is an established treatment for large or giant wide-necked unruptured intracranial aneurysms. In the past few years, the use of flow diverter devices was extended to several other "off-label" indications, including solitary or adjunctive treatment to coil embolization for direct (Barrow A type) carotid cavernous fistulas (CCFs). The use of liquid embolic agents still represents the first-line treatment for indirect CCFs. Typically, the ipsilateral inferior petrosal sinus or superior ophthalmic vein (SOV) is the preferred transvenous routes to access CCFs. In some cases, vessel tortuosity or different features make the endovascular access challenging, thus requiring different approaches and strategies. The aim of the study is to discuss rational and technical aspect in treating indirect CCFs referring to the most up-to-date literature. An alternative experience-based endovascular strategy with FD is described. We report the case of a 54-year-old woman diagnosed with indirect CCF and treated with flow diverter stent. After multiple unsuccessful attempts at transarterial right SOV catheterization, a right indirect CCF fed by a single trunk at the ophthalmic origin from the internal carotid artery (ICA) was treated by ICA stand-alone FD. Blood flow was redirect and successfully reduced through the fistula, with immediately postprocedure improvement of the patient's clinical status (ipsilateral proptosis and chemosis). Ten-months radiological follow-up showed the complete obliteration of the fistula. No adjunctive endovascular treatment was performed. FD appears a reasonable alternative stand-alone endovascular strategy also for selected difficult-to-access indirect CCFs, when all conventional routes are judged unfeasible. Further investigations will be necessary to better define and support this potential lesson-learned application.

A Troublesome Case of Indirect Carotid-Cavernous Fistula Presenting with Proptosis without Pulsation.

In this case report we represent a rare case of indirect carotid cavernous fistula (CCF) in middle-age man. A 56 year-old male presented to emergency room with a history of redness, swelling in his left eye and binocular diplopia for ten days. Upon questioning, he revealed that he had complaints about his left eye ongoing for ten months but it got worse for the last ten days. he had proptosis, chemosis with engorged and dilated scleral veins, restricted extraocular movements .After Orbital CT, CT venography, DSA performed and confirmed the diagnosis of CCF. The CCF was embolized. Our case report demonstrates how CCF is a vision threatening disease that can be easily misdiagnosed, especially in indirect fistulas with more indolent symptoms and satisfying prognostic outcome can be achieved with prompt diagnosis and treatment

The clinical features, angiographic and endovascular treatment of indirect carotid cavernous fistulas

Indirect carotid cavernous fistulas (ICCFs) are rare disease entities triggered by indirect low flow between the cavernous sinus and the meningeal branches of the internal or external carotid artery or from both. To evaluate clinical characteristics, angiography, and relationship to the result of endovascular treatment of indirect carotid cavernous fistulas. A prospective study of 32 patients diagnosed to identify ICCFs through digital subtraction angiography (DSA) and intravascular intervention. Results showed that indirect carotid cavernous fistulas were more common in females of advanced age (68.8%) and occurred spontaneously (87.5%); the most common symptoms included chemosis (93.75%), headache (87.5%), proptosis (53.1%), and tinnitus (37.5%) with type D being the most common (81.2%). Thirty out of thirty-two patients with intervention had complete flow block (83.3%), near complete (13.3%), and failure in one case. Incomplete occlusion interventions and failures were of the type D complication. The complication and number of drainage veins are related (p<0.05). ICCFs have diverse symptoms that depend on the drainage veins but most commonly were red eyes, headache, and protruding eyes. The ICCFs were mostly D-type formation and endovascular treatments were safe and effective. Common complications occurred in the case of many veins draining.

What is the most effective method to treat indirect carotid-cavernous fistula?

To review the most relevant treatment options for indirect carotid-cavernous fistulas (iCCF), cohorts of 20 patients or more published after 2000 were analyzed. Clinical and radiological outcomes, as well as embolization techniques and material, had to be clarified in the study to be considered. Statistical analysis was based on calculating the relative percentage of therapeutic methods or embolic material, followed by calculating parametric and nonparametric correlations. Some 22 studies and 1550 patients were included. Transvenous embolization (TVE) was used in 53% of the patients and was strongly associated with coiling (rw = 0.66, p = 0.0.0012; rs = 0.53, p = 0.0138), transarterial embolization (TAE) was preferred in 11% of the patients and was strongly linked to liquid embolics (rw = 0.44, p = 0.0434;rs = 0.64, p = 0.0018). A combination of TAE and TVE treatment was used in 7% and a combination of embolic materials in 13% of the patients. None of the endovascular techniques or embolization materials showed significant superiority over the others in clinical outcome and obliteration rate. Radiosurgery in 22% and mechanical compression in 5% of patients showed a lower obliteration rate (rw = - 0.48, p = 0.0254; rs = - 0.45, p = 0.0371). The clinical outcomes were comparable to endovascular treatment (EVT). The remaining 2% of the patients were treated by open surgery or a combination of EVT and radiosurgery. Transvenous coiling is the preferred EVT method for iCCF. However, comparable results may be accomplished with TAE using liquid. Radiosurgery may achieve a lower percentage of fistula occlusion, but the clinical results are equal to EVT.

Intermittent Manual Carotid Compression as a Treatment Option for Indirect Low Flow Carotid Cavernous Fistula

ABSTRACT Purpose To evaluate the efficacy of intermittent manual carotid compression (IMCC) in the management of low-flow carotid cavernous fistulae (CCF). Materials and methods Patients diagnosed with low-flow CCF and treated with IMCC over a period of 13 years were retrospectively analyzed. Data analyzed included demographic details, clinical features, type of CCF, and response to therapy. Outcomes were categorized as complete cure, partial cure, and no cure or worsening. Patients with complete and partial cure were grouped as good outcome whereas those with no cure or worsening as poor outcome. Results A total of 44 patients were advised IMCC for low-flow CCF, of whom five were lost to follow-up. Results of the remaining 39 patients were analyzed, of whom 21 (53.8%) were males. The mean age at presentation was 54.38 ± 14.54 years. The median duration between the onset of symptoms and presentation was 5.0 ± 4.10 months. The common presenting features were episcleral congestion and proptosis (89.7%), extraocular motility restriction (66.7%), and diplopia (48.7%). Most common CCF type was type D (34, 87.2%). All patients were advised to undergo IMCC. Good outcome was seen in 35 patients (89.7%, 95% CI: 80.2% to 99.2%), whereas poor outcome was seen in four (10.3%) patients. The mean duration of follow-up was 15.91 ± 21.87 months. Conclusion The present study found a good outcome with IMCC in 89.7% cases of indirect low-flow CCF with no major complications. It should be considered the management of choice in patients who are systemically unfit or cannot afford endovascular embolization.

Endovascular Management of Spontaneous Indirect Carotid- Cavernous Fistula

Carotid cavernous fistulas (CCF) are abnormal communications inducing shunting of blood between the carotid arterial system and the cavernous sinus (CS), resulting in flow reversal in the veins draining through the CS.1 CCFs can be classified as spontaneous or traumatic according to the etiology and direct or indirect (dural) according to the anatomical features2. The authors have dealt a case of a spontaneous indirect Carotid-Cavernous Fistula in a young male of 30 on the right side. The patient presented with headache and bulging of right eye. On examination there was pulsatile proptosis on the right side with conjunctival congestion. CT angiography revealed CCF on the right side with dilated, tortuous right ophthalmic and common facial vein. DSA revealed indirect Carotid-Cavernous Fistula fed by right middle meningeal artery (MMA), accessory meningeal artery and branch of right ophthalmic artery(OA) drained by right ophthalmic vein with abnormal communication via right common facial vein. Patient underwent transarterial embolization with ONYXR . DSA revealed total obliteration of fistula. Headache subsided and proptosis reduced immediately after embolization on procedure table with intact neurology. Almost two months down the follow up revealed complete recovery of proptosis and conjunctival congestion with no further headache. Bang. J Neurosurgery 2022; 11(2): 128-133

Partial Transvenous Coil Embolization with Significant Clinical Improvement in Patient with Indirect Carotid Cavernous Fistula

Highlight: CCF is a rare vascular malformation with challenging management. Partial transvenous embolization is quite effective as an alternative therapy for indirect CCF type D. ABSTRACT Introduction: An indirect carotid-cavernous fistula (CCF) is an abnormal connection between the internal or external carotid artery and the cavernous sinus. The optic, trochlear, abducens, and trigeminal nerves are located in the cavernous sinus. Head Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI), and Cerebral Angiography are some imaging modalities used to establish and diagnose carotid-cavernous fistula. Endovascular intervention can be performed with trans-arterial or trans-venous access. In some cases, complete embolization by endovascular treatment is not possible because of difficult angioarchitecture. Case: A 61-year-old female reported having pain in her left eye (numerical rating scale was 6). The left eye was bulging, reddish, ptosis, and unable to move. The patient felt double vision when opening both eyes, complained of intermittent stabbing headaches on the left side, and heard a bruit from the left side of the head. The cerebral angiography showed bilateral indirect CCF Barrow type D. The procedure involved partial transvenous embolization with coiling. The angiographic evaluation showed partial occlusion, and residual flow from the fistula was still visible on angiography. There was a significant clinical improvement several days after the procedure and a five-month follow-up. Conclusion: This case report showed that partial targeted transvenous embolization is quite effective in indirect CCF when complete embolization is impossible.

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).

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.