Carotid-Cavernous Fistula from the Perspective of an Ophthalmologist. A Review

Carotid-cavernous fistula (CCF) is an abnormal communication - vascular connection between arteries and veins in the cavernous sinus. Classification according to etiology is traumatic vs spontaneous. According to blood flow rate per high flow vs low flow fistula. According to anatomy of direct vs indirect: Direct (direct) CCF arises through direct communication between the internal carotid artery (ICA) and the cavernous sinus. Indirect CCF originates through indirect communication through the meningeal branches of ICA, external carotid artery and cavernous sinus (not directly with ICA) and Barrow type A, B, C, D division. Patient‘s subjective complaints depend on the type of CCF. Most often it is pulsating tinnitus, synchronous with blood pulse. Typical findings include protrusion and pulsation of the eyeball, corkscrew vessels - arterialization of conjunctival and episleral vessels, increased intraocular pressure, not responding to local antiglaucomatous therapy, keratopathy a lagophthalmo, corneal ulcers. In the later untreated stages of CCF, secondary, venous stasis or central retinal vein occlusion can occur. Diagnostic procedures include B-scan and color Doppler ultrasonography, digital ophthamodynamometry, computer tomography, nuclear magnetic resonance and digital subtraction angiography. CCF can simulate orbitopathy, conjunctivitis symptoms, carotid occlusion, scleritis or cavernous sinus thrombosis. The ophthalmologist should recognize and indicate the necessary examinations in a timely manner. The therapy is ophthalmological, neuroradiological, sterotactic, surgical and conservative.

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Transarterial Embolization of an Indirect Carotid- Cavernous Fistula with N-Butyl Cyanoacrylate

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v25i2.1109 ◽

2018 ◽

Vol 25 (2) ◽

pp. 150-156

Author(s):

Matías Negrotto ◽

Roberto Crosa ◽

Alejandra Jaume ◽

Fiorella Casanova

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Transarterial Embolization ◽

External Carotid Artery ◽

External Carotid ◽

Carotid Cavernous Fistula ◽

Cavernous Fistula ◽

Carotid Cavernous Fistulas

Carotid-cavernous fistulas are vascular shunts that allow blood to flow from the carotid artery into the cavernous sinus. Some fistulas are characterized by a direct connection between the cavernous segment of the internal carotid artery and the cavernous sinus. Other carotid-cavernous fistulas are dural, consisting of a communication between the cavernous sinus and one or more meningeal branches of the internal carotid artery, the external carotid artery, or both. Endovascular management is the treatment modality of choice in these cases. We report the use of N-butyl cyanoacrylate in a successful transarterial embolization of a dural carotid-cavernous fistula fed by arterial branches of the internal -and mainly- external carotid arteries (Barrow type D).

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Venous rupture during transvenous approach to a carotid-cavernous fistula

Journal of Neurosurgery ◽

10.3171/jns.1989.71.1.0133 ◽

1989 ◽

Vol 71 (1) ◽

pp. 133-137 ◽

Cited By ~ 14

Author(s):

Wesley A. King ◽

Grant B. Hieshima ◽

Neil A. Martin

Keyword(s):

Carotid Artery ◽

Cavernous Sinus ◽

Balloon Occlusion ◽

Alternative Methods ◽

Ocular Motility ◽

Carotid Cavernous Fistula ◽

Content Type ◽

Cavernous Fistula ◽

A Minor ◽

Transvenous Approach

✓ An attempt at transfemoral transarterial balloon occlusion of a high-flow spontaneous carotid-cavernous fistula was unsuccessful because the carotid artery rent was too small for this approach. During a subsequent transvenous approach to the cavernous sinus through the jugular vein, the inferior petrosal sinus was perforated. A minor subarachnoid hemorrhage occurred before the tear could be sealed by the deposition of three Gianturco coils in the vein. The patient was taken to the operating room for emergency obliteration of the fistula and petrosal sinus in order to remove the risk of further hemorrhage. Under the guidance of intraoperative digital subtraction angiography, isobutyl-2-cyanoacrylate was injected directly into the surgically exposed cavernous sinus. Successful obliteration of the fistula was achieved with preservation of the carotid artery, and the angiography catheter was removed safely from the petrosal sinus. Although initially after surgery the patient had nearly complete ophthalmoplegia, at her 1-year follow-up examination she had normal ocular motility and visual acuity. The transvenous approach to the cavernous sinus and alternative methods of treatment of carotid-cavernous fistulas are discussed.

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External carotid-cavernous sinus fistula diagnosed by common carotid arteriography

Journal of Neurosurgery ◽

10.3171/jns.1974.41.4.0494 ◽

1974 ◽

Vol 41 (4) ◽

pp. 494-498 ◽

Cited By ~ 1

Author(s):

Louis Wener ◽

Giovanni Di Chiro ◽

Robert A. Mendelsohn

Keyword(s):

Cavernous Sinus ◽

Carotid Arteries ◽

External Carotid ◽

Carotid Cavernous Fistula ◽

Content Type ◽

Cavernous Fistula ◽

Carotid Cavernous Sinus Fistula ◽

The Difference ◽

Fine Print

✓ An external carotid-cavernous fistula diagnosed by serial common carotid arteriography is reported. The diagnosis was reached on the basis of the difference in time between filling of the distal internal and external carotid arteries and the visualization of the fistula.

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Saphenous vein graft bypass in the treatment of giant cavernous sinus aneurysms: report of two cases

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2000000100025 ◽

2000 ◽

Vol 58 (1) ◽

pp. 162-168 ◽

Cited By ~ 5

Author(s):

RICARDO RAMINA ◽

MURILO S. MENESES ◽

ARI A PEDROZO ◽

WALTER O. ARRUDA ◽

GUILHERME BORGES

Keyword(s):

Carotid Artery ◽

Cavernous Sinus ◽

Saphenous Vein ◽

Vein Graft ◽

Saphenous Vein Graft ◽

Brain Infarction ◽

Superficial Temporal Artery ◽

High Flow ◽

Low Flow ◽

External Carotid

Two cases of giant intracavernous aneurysms treated by high flow bypass with saphenous vein graft between the external carotid artery (ECA) and branches of the middle cerebral artery (MCA) are presented. Very often these aneurysms are unclippable because they are fusiform or have a large neck. Occlusion of the internal carotid artery (ICA) is the treatment of choice in many cases. This procedure has however a high risk of brain infarction. Revascularization of the brain by extra-intracranial anastomosis between the superficial temporal artery (STA) and branches of the MCA is frequently performed. This procedure provides however a low flow bypass and brain infarction may occur. We report two cases of giant cavernous sinus aneurysms treated by high flow bypass and endovascular balloon occlusion of the ICA. Immediate high flow revascularization of MCA branches was achieved and the patients showed no ischemic events. Follow-up of 8 and 14 months after operation shows patency of the venous graft and no neurological deficits. Angiographic control examination showed complete aneurysm occlusion in both cases.

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External carotid-cavernous fistula treated by arterial embolization

Journal of Neurosurgery ◽

10.3171/jns.1974.40.1.0110 ◽

1974 ◽

Vol 40 (1) ◽

pp. 110-114 ◽

Cited By ~ 20

Author(s):

M. Stephen Mahalley ◽

Stephan C. Boone

Keyword(s):

Carotid Artery ◽

Successful Treatment ◽

Arterial Embolization ◽

External Carotid Artery ◽

External Carotid ◽

Carotid Cavernous Fistula ◽

Content Type ◽

Cavernous Fistula ◽

Unusual Occurrence ◽

Fine Print

✓ The unusual occurrence of a carotid-cavernous fistula supplied entirely by branches of the external carotid artery is presented, and its successful treatment by arterial embolization described.

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Treatment of Trapped CCF by Direct Puncture of the Cavernous Sinus by Infraocular Trans-SOF Approach

Interventional Neuroradiology ◽

10.1177/159101990200800310 ◽

2002 ◽

Vol 8 (3) ◽

pp. 299-304 ◽

Cited By ~ 12

Author(s):

M.J. Workman ◽

J.E. Dion ◽

F.C. Tong ◽

H.J. Cloft

Keyword(s):

Carotid Artery ◽

Cavernous Sinus ◽

Operative Technique ◽

Carotid Cavernous Fistula ◽

Artery Ligation ◽

Direct Puncture ◽

Cavernous Fistula ◽

Carotid Artery Ligation ◽

Anatomical Basis

We present a case of recurrent carotid-cavernous fistula after prior ipsilateral carotid artery ligation. Due to lack of endovascular access, embolization was performed by direct puncture of the cavernous sinus via a transorbital approach. Operative technique and an anatomical basis for treatment are described.

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Post-traumatic carotid-cavernous fistula with bilateral proptosis simulating cavernous sinus thrombosis

BMJ Case Reports ◽

10.1136/bcr-2018-227757 ◽

2019 ◽

Vol 12 (3) ◽

pp. e227757 ◽

Cited By ~ 1

Author(s):

Nirupama Kasturi ◽

Pooja Kumari ◽

Gayatri Nagarajan ◽

Nagarajan Krishnan

Keyword(s):

Cavernous Sinus ◽

Sinus Thrombosis ◽

Cavernous Sinus Thrombosis ◽

Coil Embolisation ◽

Carotid Cavernous Fistula ◽

Orbital Trauma ◽

Cavernous Fistula ◽

Intravenous Antibiotics ◽

Post Traumatic

A 48-year-old woman presented with bilateral non-pulsatile proptosis and ophthalmoplegia after 3 days following blunt orbital trauma. It was associated with fever, malaise and loss of vision in right eye. She was provisionally diagnosed with cavernous sinus thrombosis and was treated with intravenous antibiotics with no improvement. A subtle bruit was present on examination, and digital subtraction angiography revealed a right direct (type A) carotid-cavernous fistula (CCF). The patient underwent right coil embolisation of direct CCF. On follow-up at 4 months, her proptosis resolved completely and extraocular movements improved.

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Electrothrombosis of Spontaneous Carotid-Cavernous Fistula by Copper Needle Insertion

Neurosurgery ◽

10.1097/00006123-198404000-00002 ◽

1984 ◽

Vol 14 (4) ◽

pp. 400-405 ◽

Cited By ~ 1

Author(s):

Nishijima Michiharu ◽

Kamiyama Kazuyo ◽

Oka Nobuo ◽

Endo Shunro ◽

Takaku Akira

Keyword(s):

Carotid Artery ◽

Nerve Palsy ◽

Internal Carotid ◽

Needle Insertion ◽

External Carotid Artery ◽

External Carotid ◽

Carotid Cavernous Fistula ◽

Intraoperative Angiography ◽

Cavernous Fistula ◽

Gerstmann’S Syndrome

Abstract Electrothrombosis by copper needle insertion was used to treat three cases of spontaneous carotid-cavernous fistula. These patients had been treated conservatively for 6 months or more, but their symptoms had not improved. Angiography showed that the feeding arteries were branches of both the ipsilateral internal and the ipsilateral external carotid artery. Frontotemporal craniotomy was performed, and copper needles were inserted transdurally into the cavernous sinus. Closure of the fistula was verified by intraoperative angiography in all cases, and the symptoms improved after the operation. However, one patient had postoperative transient 3rd nerve palsy. Another had Gerstmann's syndrome due to narrowing of the internal carotid artery by a needle and worsening of the preoperative 6th nerve palsy. In one case, the operation was uneventful. Based on our experience, we discuss several problems with this technique.

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