Bilateral Carotid-Cavernous Fistulas: An Uncommon Cause of Pituitary Enlargement and Hypopituitarism

Carotid-cavernous fistulas (CCFs) are rare, pathologic communications of the carotid artery and the venous plexus of the cavernous sinus. They can develop spontaneously in certain at risk individuals or following traumatic head injury. Typical clinical manifestations include headache, proptosis, orbital pain, and diplopia. We report a case of bilateral carotid-cavernous fistulas associated with these symptoms and also with pituitary enlargement and hypopituitarism, which improved following surgical intervention. Arterialization of the cavernous sinus and elevated portal pressure may interfere with normal venous drainage and the conveyance of inhibiting and releasing hormones from the hypothalamus, resulting in pituitary enlargement and hypopituitarism. This condition should be considered in the differential diagnosis of hypopituitarism associated with anterior pituitary enlargement.

Download Full-text

Successful surgical treatment of bilateral carotid-cavernous fistulas

Journal of Neurosurgery ◽

10.3171/jns.1975.43.3.0357 ◽

1975 ◽

Vol 43 (3) ◽

pp. 357-361 ◽

Cited By ~ 13

Author(s):

Frances K. Conley ◽

Richard D. Hamilton ◽

Yoshio Hosobuchi

Keyword(s):

Surgical Treatment ◽

Cavernous Sinus ◽

Content Type ◽

Bilateral Carotid ◽

Carotid Cavernous Fistulas ◽

Fine Print

✓ The authors report a case of traumatic bilateral carotid-cavernous sinus fistulas, successfully treated by surgical electrothrombosis of both cavernous sinuses.

Download Full-text

Traumatic Bilateral Carotid-Cavernous Fistulas Treated with Detachable Balloon

Acta Radiologica ◽

10.1177/02841851960371p109 ◽

1996 ◽

Vol 37 (1P1) ◽

pp. 46-48 ◽

Cited By ~ 12

Author(s):

J. K. Kim ◽

J. J. Seo ◽

Y. H. Kim ◽

H. K. Kang ◽

J. H. Lee

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Venous Drainage ◽

Balloon Occlusion ◽

Detachable Balloon ◽

Balloon Occlusion Test ◽

Bilateral Carotid ◽

The Right ◽

Carotid Cavernous Fistulas

A 29-year-old male developed ptosis and progressive pulsating protrusion of the right eye, accompanied by conjunctival injection and tinnitus following a bicycle accident. MR angiography revealed dilation of both superior ophthalmic veins and facial veins. Right internal carotid angiography demonstrated right carotid-cavernous fistula (CCF) at the C3 portion of the right internal carotid artery with abnormal venous drainage. After right carotid balloon occlusion test had been performed, a detachable balloon was introduced into the right CCF while preserving the lumen of the right internal carotid artery. A left CCF, which was detected after closure of the right CCF, was also closed with a detachable balloon. Follow-up carotid angiographies showed complete closure of both CCFs and no abnormal venous drainage. After 1 year no abnormal physical manifestations, or abnormal neurologic signs or symptoms were present.

Download Full-text

Transvenous Embolisation of Spontaneous Carotid-Cavernous Fistulas by Sequential Occlusion of the Cavernous Sinus

Interventional Neuroradiology ◽

10.1177/159101999900500305 ◽

1999 ◽

Vol 5 (3) ◽

pp. 225-234 ◽

Cited By ~ 9

Author(s):

K.-M. Cheng ◽

C.-M. Chan ◽

Y.-L. Cheung ◽

C.-C. Liang ◽

M.-K. Lee ◽

...

Keyword(s):

Cavernous Sinus ◽

Clinical Cure ◽

Venous Drainage ◽

Clinical Results ◽

Late Complications ◽

Pathological Features ◽

Cortical Venous Drainage ◽

The Right ◽

Carotid Cavernous Fistulas

There are two important pathological features associated with carotid-cavernous fistula (CCF): the retrograde cortical venous drainage that can cause intracranial haemorrhage and non haemorrhagic neurological deficit and the retrograde ophthalmic venous drainage that causes orbital venous congestion and visual impairment. We propose a sequential embolisation strategy by the selective occlusion of these two pathological features as the initial steps followed by occlusion of the rest of the cavernous sinus. Eight patients with spontaneous CCF were treated by transvenous embolisation using our embolisation strategy. The clinical features, angiographic findings, embolisation procedures, and clinical and angiographic outcomes were analyzed. The follow-up period ranged from one to 21 months. Clinical cure was achieved in six patients at one to two month follow-ups. One patient with bilateral CCFs had clinical cure of the right eye and clinical improvement of the left eye at three-month follow-up. Another patient had clinical cure at one-month follow-up except residual VI nerve palsy. Two patients had complete angiographic obliteration of the fistula immediately after the embolisation procedure. Another three patients underwent follow-up angiography at one to 16 months and all showed angiographic cure. There were no immediate or late complications. Our embolisation strategy offers a safe and effective option in the embolisation of spontaneous CCF as demonstrated by the clinical results of our eight patients.

Download Full-text

Carotid Cavernous Fistulas and Dural Arteriovenous Fistulas of the Cavernous Sinus: Validation of a New Classification According to Venous Drainage

World Neurosurgery ◽

10.1016/j.wneu.2019.04.220 ◽

2019 ◽

Vol 128 ◽

pp. e621-e631 ◽

Cited By ~ 1

Author(s):

Giuseppe Leone ◽

Leonardo Renieri ◽

Alejandro Enriquez-Marulanda ◽

Adam A. Dmytriw ◽

Sergio Nappini ◽

...

Keyword(s):

Cavernous Sinus ◽

Venous Drainage ◽

New Classification ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Carotid Cavernous Fistulas

Download Full-text

Spontaneous Bilateral Carotid-Cavernous Fistulas Secondary to Cavernous Sinus Thrombosis

Neurosurgery ◽

10.1093/neuros/nyw128 ◽

2017 ◽

Vol 80 (4) ◽

pp. 646-654 ◽

Cited By ~ 8

Author(s):

Fawaz Al-Mufti ◽

Krishna Amuluru ◽

Mohammad El-Ghanem ◽

Abhinav R. Changa ◽

Inder Paul Singh ◽

...

Keyword(s):

Cavernous Sinus ◽

Endovascular Therapy ◽

Sinus Thrombosis ◽

Anticoagulation Therapy ◽

Cavernous Sinus Thrombosis ◽

Adequate Treatment ◽

Bilateral Carotid ◽

Carotid Cavernous Fistulas

Abstract Bilateral carotid cavernous fistulas are rare entities that can cause debilitating symptoms and can lead to more severe consequences if left untreated. Therefore, the recognition and adequate treatment of these pathologies is very important. We present 2 cases of bilateral carotid cavernous fistulas that arose as a result of cavernous sinus thrombosis. We review the literature and discuss the pathophysiology, symptomatology, management, and treatment of bilateral carotid cavernous fistulas. Within our own cases, treatment of the patients was varied. The patient in case 1 was successfully treated with endovascular therapy after a failed trial of anticoagulation. The patient in case 2 demonstrated resolution of bilateral carotid cavernous fistulas after anticoagulation therapy. Case 2 highlights the fact that certain cases of bilateral carotid cavernous fistulas due to cavernous sinus thrombosis may benefit from extensive anticoagulation therapy. If anticoagulation therapy is unsuccessful, endovascular therapy may prove beneficial in resolving the fistulous shunt.

Download Full-text

Treatment of a carotid cavernous fistula via direct transovale cavernous sinus puncture

Journal of Neurosurgery ◽

10.3171/2013.4.jns121504 ◽

2013 ◽

Vol 119 (1) ◽

pp. 247-251 ◽

Cited By ~ 10

Author(s):

Alberto Gil ◽

Luis López-Ibor ◽

Gerardo Lopez-Flores ◽

Hugo Cuellar ◽

Eduardo Murias ◽

...

Keyword(s):

Cavernous Sinus ◽

Venous Drainage ◽

Foramen Ovale ◽

Superior Ophthalmic Vein ◽

Carotid Cavernous Fistula ◽

Cavernous Fistula ◽

Complete Obliteration ◽

Feasible Alternative ◽

Carotid Cavernous Fistulas

Endovascular treatment is the treatment of choice for indirect carotid cavernous fistulas (CCFs). Direct surgical obliteration of CCFs is recommended in highly symptomatic patients or in those with an aggressive pattern of venous drainage. However, this is a technically challenging approach associated with significant procedural morbidity. The authors present a case in which they decided to attempt a novel access to the cavernous sinus through the foramen ovale before recommending surgery for an otherwise untreatable dural CCF. This 52-year-old man with an indirect CCF and neurological deficit had undergone several attempts to embolize the shunt by means of the standard approaches. Ultimately direct cavernous sinus access was obtained through the foramen ovale, resulting in complete obliteration of the shunt. The occlusion was radiographically stable at the 6-month follow-up evaluation, and the patient has remained asymptomatic. Percutaneous transovale puncture of a CCF is a feasible alternative to accessing the cavernous sinus when traditional transvenous catheterization or direct superior ophthalmic vein approach is not possible.

Download Full-text

CAROTID-CAVERNOUS FISTULA (CCF) - A REVIEW

10.36106/gjra/2000516 ◽

2021 ◽

pp. 12-14

Author(s):

Abhas Kumar ◽

Malavika B G

Keyword(s):

Cavernous Sinus ◽

Clinical Manifestations ◽

Venous Drainage ◽

Review Article ◽

Arterial System ◽

Carotid Cavernous Fistula ◽

Vascular Connection ◽

Ophthalmic Manifestations ◽

Expected Outcome ◽

Life Threatening

A carotid-cavernous stula (CCF) is the result of an abnormal vascular connection between the carotid system (ICA/ECA) and the venous channels of the cavernous sinus. CCFs are classied based on the arterial system involved, hemodynamics, and etiology. The presentation can be varied and nonspecic; commonly presents with ophthalmic manifestations due to impairment of venous drainage of the orbit from the cavernous sinus. Early diagnosis and appropriate management is essential to avoid vision and life-threatening complications. Patients with CCF may initially present to an ophthalmologist with decreased vision, conjunctival chemosis, external ophthalmoplegia and proptosis. Ophthalmologist may be the rst physician to encounter a patient with clinical manifestations of CCF, and this review article should help in understanding the clinical features of CCF, current diagnostic approach, usefulness of the available imaging modalities, possible modes of treatment and expected outcome.

Download Full-text