Indirect Fistula Research Articles

CAROTID - CAVERNOUS FISTULA - CCF

Carotid-cavernous fistulas are a rare vascular disorder resulting from an abnormal connection between the cavernous sinus and the carotid arteries. Direct carotid-cavernous fistulas require endovascular treatment. Indirect fistulas may resolve spontaneously or with non-invasive treatment, but worsening symptoms may also require endovascular treatment. Endovascular treatment is performed using detachable balloons, detachable coils, stents, and embolization materials such as n-BAC or Onyx. The symptoms occur as a result of increased pressure within the venous drainage vessels. The most common clinical manifestation are symptoms within the eyeball. Due to their rare occurrence and often non-uniform clinical symptoms, carotid-cavernous fistulas may pose diagnostic difficulties. The Aim of this work: Carotid-cavernous fistula is a disorder that may result in complete loss of vision. Appropriate diagnostics and the involvement of an interdisciplinary team of specialists are important. Such a team should consist of an ophthalmologist, a radiologist and a neurosurgeon. The fistula requires differentiation from other more common diseases with similar symptoms, hence the knowledge of the etiology, diagnosis and treatment of the fistula is crucial. Methods: Selected articles from Pubmed and specialist literature were analyzed in detail. We focused on selected issues related to carotid-cavernous fistulas. Conclusion: When the clinical symptoms are vague, the diagnosis may be incorrect or established with a long delay. Early correct diagnosis can effectively prevent irreversible vision impairment.

Indirect Fistula: A New Terminology for Cerebrospinal Fluid Fistula With Different 'Apparent Origin' and 'Real Origin'.

Fistulas are abnormal communications between body cavities. They can occur between the CNSand the extracranial space, presenting clinically as CSFleaks. Due to the variety of features, multiple classifications have been implemented to better study this pathology. A systematic review was conducted using the Scopus, Medline, and Web of Science databases. Observational studies such as cohort studies, case reports, case series, cross-sectional studies, systematic reviews, and publications that assess the classification of CSF leaks were included. The systematic review identified 29 publications that met the required criteria for inclusion. Although the primary focus of most of these publications was not on classification, they briefly mentioned it. The included publications describe classifications according to etiology, exiting flow pressure, anatomic site, and some new classification proposals. Of the 29 included studies, 11 referred to the appearance of CSF rhinorrhea or otorrhea with no relationship between the cause or site of origin and the site of the CSF leak. However, none of these publications names this situation. These results clearly indicate that a term for this circumstance needs to be established; none of the previously listed publications provide a name for this condition. This systematic review aims to demonstrate the necessity of implementing a new term to describe CSF leaks where the 'apparent origin' does not correspond to the 'real origin.' The results show no existing term that considers such cases; therefore, we propose the term 'Indirect Fistula' to designate these cases.

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.

Abstract Number ‐ 80: Embolization of Carotid Cavernous Fistula Through Occluded Inferior Petrosal Sinus Access

Introduction Carotid cavernous fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus. The most common presenting symptoms are proptosis, chemosis, orbital bruit and headache. Visual disturbances such as diplopia, ophthalmoplegia and cranial nerve deficits can also occur. Pulsatile tinnitus is an unusual finding which necessitates further workup in this population. Endovascular obliteration with transvenous embolization for indirect fistulas is the preferred approach for CCF closure. Navigation is achieved through the inferior petrosal sinus or facial and superior ophthalmic vein. Here, we describe a case of carotid cavernous fistula that was successfully treated through occluded right inferior petrosal sinus access using coil and Onyx embolic material. Methods A 56‐year‐old‐male with no past medical history presented with right eye proptosis and pulsatile tinnitus. His eye symptoms progressively worsened with decrease in visual acuity, gaze restriction and exophthalmos which correlated with the resolution of pulsatile tinnitus. MRI demonstrated significant inflammation involving the right orbit and atypical enhancement of basal frontal lobe adjacent to orbit. MRA suggested early opacification of the right superior ophthalmic vein and subtle flow voids in posterior lateral aspect of right cavernous sinus. Further evaluation with cerebral angiogram revealed a Barrow Type D right carotid cavernous fistula supplied by meningo‐hypophyseal branches of bilateral internal carotid arteries and right internal maxillary branch. It demonstrated high flow retrograde shunting in right superior ophthalmic vein and a basal frontal isolated cortical vein. There was near complete occlusion of the right sigmoid sinus and inferior petrosal sinus due to significant thrombus burden as well as stenosis of the right internal jugular vein. Results Patient underwent embolization of right carotid cavernous fistula with transvenous approach. A microcatheter was advanced to the origin of the intercavernous sinus but was not able to cross due to exceptionally small channels connecting both cavernous sinuses. The right internal jugular vein was subsequently identified and injection demonstrated occlusion of right sigmoid sinus due to near complete occlusive thrombus in addition to occlusion of the major channels of the inferior petrosal sinus. The microcatheter was blindly advanced into the inferior petrosal sinus maintaining the symmetry from contralateral inferior petrosal sinus trajectory. We were able to reach the fistulous point in the posterior medial aspect of the right cavernous sinus using an Echelon 1045 microcatheter. Coils were subsequently deployed and fistula was noted to be occluded. Onyx was injected through the microcatheter to avoid recanalization of fistula. A follow‐up left internal carotid artery and right common carotid artery injections confirmed angiographic cure of the fistula. Conclusions Carotid cavernous fistula is a rare but treatable cause of rapidly progressive vision loss with pulsatile tinnitus as an unusual finding. We present a case of challenging access and successful treatment with transvenous approach through near complete occlusion of the inferior petrosal sinus.

Superior ophthalmic approach in carotid-cavernous fistula: current concepts in indications, surgical techniques, and case reviews.

Carotid-cavernous fistulas, characterized by abnormal arteriovenous communication within the cavernous sinus (CS), can be classified as direct or indirect. Direct fistulas are defined as a direct connection between the internal carotid artery (ICA) and CS, whereas indirect fistulas result from an abnormal connection between the CS and dural arterial branches. The first-line treatment for both types of fistulas is endovascular intervention, most commonly accomplished through the transarterial and transvenous approaches of the conventional pathway, including the ICA, inferior and superior petrosal sinuses, or basilar plexus. Nonetheless, a retrograde approach through the superior ophthalmic vein may be necessary for individuals in whom conventional endovascular treatment fails. Herein, the current principles of surgical indication and technique are presented, along with case studies.

Indirect cholecystoduodenal fistula via hepatoduodenal ligament secondary to gangrenous cholecystitis: a case report

BackgroundCholecystoduodenal fistula is an infrequent complication of gallbladder diseases. In the majority of cases, the fistula is formed by direct communication between the gallbladder and duodenum due to gallstone impaction in the gallbladder neck. We herein report a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis.Case presentationAn 80-year-old woman suspected of having emphysematous cholecystitis by a previous doctor was referred to our hospital for urgent surgery. The initial diagnosis based on additional examinations was gangrenous cholecystitis penetrating the hepatoduodenal ligament. Since she did not complain of signs of peritonitis and was taking an anticoagulant medicine, we avoided surgery and selected percutaneous gallbladder drainage (PTGBD) instead. Contrast imaging of the PTGBD tube and upper endoscopy identified the indirect cholecystoduodenal fistula via the hepatoduodenal ligament. Despite repeated attempts at endoscopic fistula closure using clips, the fistula did not close successfully. We therefore performed laparoscopic cholecystectomy and fistula closure. The postoperative clinical course was uneventful, and she left the hospital on postoperative day 15. The resected gallbladder contained small black stones, and a histological examination revealed gangrenous cholecystitis with no malignant signatures.ConclusionWe encountered a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis that was successfully treated by laparoscopic cholecystectomy and fistula closure. It is important to recognize the possible formation of indirect cholecystoduodenal fistula in cases of gangrenous cholecystitis penetrating the hepatoduodenal ligament.

A Case of a Carotid Cavernous Fistula.

Case PresentationA 73-year-old male presented to the emergency department complaining of pain in his right eye for four weeks. He denied any trauma, and the pain was accompanied by ptosis, proptosis, swelling, redness, blurred vision, and a frontal headache. On examination, conjunctival arterialization was also appreciated. Magnetic resonance imaging and angiography showed evidence of a carotid cavernous fistula for which the patient underwent successful transvenous coiling and embolization.DiscussionCarotid cavernous fistulas are classified as higher flow, direct fistulas or lower flow, indirect fistulas; the latter is more insidious in onset. Classic symptoms include conjunctival arterialization, proptosis, ptosis, palpebral edema, ocular palsy, vibratory sensation, elevated intraocular pressure without pupillary or visual acuity deficits, and headache. The treatment of choice is transvenous embolization.

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.

Onyx Embolization of Carotid-Cavernous Fistulas and Its Impact on Intraocular Pressure and Recurrence: A Case Series.

Carotid-cavernous fistulas (CCFs) are acquired pathological shunting lesions between the carotid artery and the cavernous sinus leading to elevated intraocular pressure (IOP). CCFs are commonly treated via endovascular embolization, which theoretically restores physiological pressure differentials. To present our institutional data with CCF treated with embolization and discuss endovascular routes, recurrence rates, and dynamic IOP changes. Retrospective analysis of 42 CCF patients who underwent Onyx (Covidien, Irvine, California) embolization and pre- and postoperative IOP measurement at a single institution. CCFs were 19.0% direct (type A) and 81.0% indirect (types B, C, or D). Onyx-18 liquid embolisate was used during all embolizations. Overall rate of total occlusion was 83.3% and was statistically similar between direct and indirect fistulas. Preoperative IOP was elevated in 37.5%, 100.0%, 75.0%, and 50% in type A, B, C, and D fistulas, respectively. Average ΔIOP was -7.3±8.5 mmHg (range: -33 to+8). Follow-up time was 4.64±7.62 mo. Full angiographic occlusion was a predictor of symptom resolution at 1 mo (P=.026) and 6 mo (P=.021). Partial occlusion was associated with persistent symptoms postoperatively at 1 mo (P=.038) and 6 mo follow-up (P=.012). Beyond 6 mo, negative ΔIOP was associated with continued symptom improvement. Recurrence occurred in 9.5% of patients, all of which were indirect CCFs. Onyx embolization of CCF is an effective treatment for CCF and often results in the reversal of IOP elevation. Full occlusion predicts favorable clinical outcomes up to 6 mo. Postoperative IOP reduction may indicate favorable long-term clinical outcomes.

Indirect carotico-cavernous fistula following trivial trauma causing secondary glaucoma

Indirect carotico-cavernous fistula following trivial trauma causing secondary glaucoma

Transvenous Embolization of Carotid Cavernous Fistula through Inferior Petrosal Sinus with Detachable Coils and Ethylene Vinyl Alcohol Copolymer.

Carotid cavernous fistula (CCF) is a rare disease caused by abnormal communications between the internal carotid artery (direct fistula) or meningeal branches of the external carotid artery (indirect fistula) and the cavernous sinus (CS). Trauma is the most common cause of CCF. The clinical presentation of CCF is closely related to the venous drainage pattern. Orbital and neuro-ophthalmological symptoms are the most common clinical presentation of CCF with drainage through the superior ophthalmic vein (SOV). Endovascular embolization by arterial or venous approaches is the most common management of CCF. Transvenous embolization using detachable coils and ethylene-vinyl alcohol copolymer (EVOH) is an alternative method for the treatment of CCF. Endovascular embolization offers different options to treat CCF by minimally invasive approach decreasing morbidity and residual fistulas. The purpose of this article is to report our treatment experiences via the inferior petrosal sinus (IPS), and immediate-term outcomes of endovascular embolization of CCF by using detachable coils and EVOH.

Treatment of low flow, indirect cavernous sinus dural arteriovenous fistulas with external manual carotid compression – the UK experience

Introduction: External manual carotid compression (EMCC) is a treatment option for indirect cavernous sinus dural arteriovenous fistulas (CS-DAVF). The exact mechanism of how this works is unclear but compression of the carotid and jugular produces thrombus in the cavernous sinus (CS). Although compression of the superior ophthalmic vein (SOV) has been described as a treatment option this technique is not always amenable. We studied the clinical features, imaging studies, complications and resolution of CS-DAVF in a series seven patients.Materials and methods: Between 2011 and 2017 we treated 7 patients (4 female, 3 male, age range: 60–86 years) with EMCC for an indirect, low-flow CS-DAVF (Barrow B-D). Patients compressed the cervical carotid artery on the side of the CS-DAVF using the contralateral hand for 5–10 seconds 5–10 times per day. Using gradually increasing pressure they compressed the carotid artery and jugular vein until the pulse was no longer palpable.Results: 6 patients had complete resolution of their CS-DAVF within a range of 5–24 months of symptom onset (median 8 months). 5 of our patients had complete resolution of their clinical symptoms at final follow-up. One patient had a failed endovascular procedure, and subsequently underwent surgery to cannulate the SOV for a transvenous endovascular approach to the fistula but in the meantime she had performed EMCC, which is thought to have resolved the fistula. One patient remains under follow-up and is performing EMCC.Conclusion: EMCC is a safe and low risk technique for low-flow indirect CS-DAVF and should be considered as a first line treatment for patients unable to have endovascular treatment. Although compression of the SOV has been described this can often be difficult to perform in the context of periorbital oedema. EMCC should always be performed using the contralateral hand, because this will ensure that the compressing hand falls away should cerebral ischaemia develop.:

Management of Carotid Carvenous Fistula in Ghana; Challenges and Opportunities

Carotid-cavernous fistula is an abnormal communication between the carotid artery and the cavernous sinus. The fistula is classified based on its etiology, haemodynamic and anatomical configuration. The most common type is the direct high flow fistula resulting from trauma. Indirect fistula which is less common results from underlying conditions such as hypertension, collagen vascular diseases, pregnancy amongst others. It is in regards with this uncommon occurrence of indirect fistula that we report a case of forty years old woman who presented with a left protruding eyeball and headache a month after delivery and was diagnosed with spontaneous type D indirect carotid cavernous fistula with rapidly progressing symptoms. She was referred abroad for interventional radiological services due to unavailability of such services in our facility and country.

Endovascular treatment of carotid–cavernous sinus fistulas: ophthalmic and visual outcomes

ABSTRACTPurpose: The main objective was to report the epidemiology, clinical manifestations, angiography features, treatment modality and post-treatment outcomes in patients diagnosed with carotid cavernous fistulas (CCF).Methods: A retrospective review of the medical imaging database in conjunction with medical records from 2004 to 2017 at the Royal Brisbane and Women’s Hospital (RBWH) was conducted.We identified 39 patients with CCF (16 direct, 23 indirect). A total of 37 diagnoses were confirmed by direct catheter angiography. The remaining two cases were diagnosed using magnetic resonance imaging/magnetic resonance angiography.Results: Coils were deployed in 100% of direct and 83% of treated indirect fistulas that were treated. Other embolic agents were deployed alone or in combination with coils. Successful angiographic closure was achieved in 93% of direct and 92% of indirect fistulas. Multiple treatments were required in 33% of direct and 16% of indirect fistulas. Visual acuity improved in patients with direct fistulae(p = 0.02) and was preserved in those with indirect fistulae. Post-treatment diplopia persisted in six patients with direct fistulas and three patients with indirect fistulas. Four patients with indirect fistulas experienced persistent ocular hypertension post-treatment compared to two patients with direct fistulas.Conclusions: Endovascular coils are the most commonly deployed treatment for CCF. Both indirect and direct fistulas achieved high rates of closure; however, indirect fistulas were less likely to require multiple treatments. Good post-procedural vision was achieved for both groups.

Efficacy of Orbital Color Doppler Imaging and Neuroimaging in the Diagnosis of Carotid Cavernous Fistulas.

To evaluate the diagnostic sensitivity and specificity of orbital color Doppler imaging (CDI) and conventional neuroimaging (CT/MRI) compared with cerebral angiography in patients with carotid-cavernous fistulas (CCFs). The study design was a retrospective patient chart and imaging review. The authors reviewed 655 charts of all patients who underwent CDI and neuroimaging (CT/MRI) between 2006 and 2015 at one institution. Sixty patients had a presumptive diagnosis of CCF without thrombosis. Thirty-seven patients with 43 events met the inclusion criteria of the study. The diagnostic sensitivity of the 3 noninvasive imaging modalities (CDI, CT, MRI) for CCF was compared with the gold standard 6-vessel cerebral angiography. Significance testing was performed using the 2-tailed Fisher test. Color Doppler imaging had high sensitivity (96.8%) but low specificity (41.7%) for the diagnosis of CCFs with anterior orbital findings. A negative CDI had more diagnostic value than a positive CDI. While an arterial wave form in the superior ophthalmic vein was the most common finding of CCF on CDI, enlargement of the superior ophthalmic vein was the only statistically significant finding. Posterior cortical venous drainage was noted in about 10% of the patients with indirect (low-flow) fistulas, who presented with unilateral orbital signs and symptoms, a finding not previously reported in the literature. Color Doppler imaging is a useful noninvasive, radiation-free modality for diagnosis of CCF with anterior drainage, with higher sensitivity than CT or MRI, but equivalent specificity. A significant limitation of CDI is the lack of usefulness in diagnosing fistulas with posterior cortical venous drainage, which carry a risk of intracerebral hemorrhage and stroke. In this series, 10% of unilateral CCFs with anterior orbital signs and symptoms showed angiographic evidence of posterior cortical venous drainage.

Endovascular treatment of arteriovenous anastomoses in the cavernous sinus region

Introduction. Arteriovenous fistula in the cavernous sinus is a complex vascular pathology of the brain, its’ treatment is a scabrous problem that requires optimization of used techniques. Materials and methods . In the neurosurgical clinic of Kharkov Regional Hospital — Emergency and Disaster Medicine Center 23 endovascular surgeries were performed in 21 patients with carotid-cavernous sinus and arteriovenous fistulas. Preference was given to endovascular separation using detachable balloons «GoldBalloon» BALT (France). Results . In 16 (76%) cases after endovascular surgery complete regression of ophthalmic disorders was observed. In 2 (9.5%) patients with indirect fistulas repeat embolization of external carotid artery branches was performed 6 months after first operation, complete regression of ophthalmic disorders was achieved. Conclusions. The method of choice in treatment of arteriovenous fistulas of cavernous sinus is endovascular separation using modern materials and different adhesive compositions, which significantly increase treatment effectiveness in these patients.

Bilateral indirect carotid cavernous fistula post trivial injury– A case report

Fifty-seven years old Malay lady, post menopausal with co-morbid of diabetes mellitus and hypertension presented with three months history of bilateral painful red eyes associated with double vision. Examination revealed both eyes proptosis, corkscrew vessels with present of bruit, secondary narrow angle with raised intraocular pressure, 6th cranial nerve palsy, and bilateral venous stasis retinopathy. CT angiogram showed bilateral dilated superior ophthalmic veins with cerebral angiogram findings of bilateral indirect carotid cavernous fistula involving small meningeal vessels. Indirect or dural cavernous sinus Fistula can easily be missed or misdiagnosed. Trivial injury especially in the predisposing patient can initiate the occurrence.

Fistule durale carotido-caverneuse révélée par une paralysie bilatérale à bascule des troisièmes et sixièmes nerfs crâniens

A 74-year-old male was referred for disequilibrium, associated with right third and sixth nerve palsies observed 2weeks after head trauma with no loss of consciousness. On clinical examination, 4months after the injury, contralateral (left) third and sixth nerve palsies were observed, while ocular motility was now normal on the right side. The remainder of the ophthalmological examination was normal. Upon further history, tinnitus was found to have been present since the trauma, and auscultation of the preauricular area demonstrated a systolic bruit. Cerebral angiogram confirmed the presence of bilateral dural-cavernous fistulas. Clinical features of indirect or dural-cavernous fistulas and therapeutic options proposed in the literature are reviewed.

Ophthalmologic outcome of direct and indirect carotid cavernous fistulas

Carotid cavernous fistulas (CCFs) can be classified as direct and indirect, depending on their flow rates and their etiology. Both forms can cause the same characteristic ophthalmological symptoms and signs. We analyzed these ocular characteristics and determined the prognostics factors associated with treatment outcome. Forty-seven patients with an angiographically confirmed diagnosis of CCF, a preoperative ophthalmic evaluation and at least one ophthalmic sign or symptom at the initial presentation were retrospectively evaluated. The patients were followed-up ophthalmically until the end of treatment, and the complications and the remaining ophthalmological signs and symptoms were then recorded. The patients' ages ranged from 13 to 89 years, with an average of 55.78 (±20.73) years, and a predominance of 28 female (57.8 %) patients. The patients with a direct CCF had a lower average age (p = 0.02). The most common symptoms were blurred vision in 17 (36.2 %) and proptosis in 37 (78.7 %) patients. Elevated intraocular pressure (IOP) was more prevalent in patients with an indirect CCF (p = 0.02). Thrill was more prevalent in patients with direct CCF (p = 0.01). The presence of an initial decrease of visual acuity at the first ophthalmic evaluation was significantly associated with the persistence of ocular symptoms after fistula treatment (odds ratio 3.33). In conclusion our study shows a slight difference in ophthalmic symptoms among patients with different types of fistula. Elevated IOP was significantly associated with indirect fistulas, whereas thrill was significantly associated with direct fistulas. The presence of an initial decrease of visual acuity was significantly associated with a worse ophthalmic prognosis.