Direct highflow shunt between ica and cavernous sinus, often from ruptured cavernous ica aneurysm b. This was a retrospective study of 53 patients with angiographically confirmed ccf. May 24, 2019 carotid cavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. The most frequent are type c, with meningeal branches of the external carotid forming the fistula 3. Caroticocavernous fistula radiology reference article. A carotidcavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. Posttraumatic carotidcavernous fistulas are due to a tear in the wall of the. Indirect fistulas are due to communication by multiple branches between the internal andor external carotid arteries and the cavernous sinus. Carotid cavernous fistula ccf is an abnormal communication between cavernous sinus and carotid arterial system. Apr 28, 20 the initial angiographic evaluation can be used to obtain the following information. Imaging diagnosis of dural and direct cavernous carotid fistulae ncbi. The incidence is less than 1%, 1 even in large series, and 72 to 75% are of posttraumatic origin.
Carotid cavernous fistula ccf is an abnormal communication between the cavernous sinus cs and the carotid arterial system. Four cases in which the diagnosis of carotidcavernous fistula was made by using ct angiography are illustrated. Catheter angiography confirmed a direct carotidcavernous fistula with intra and extracranial venous drainage. A ct of the sinus can help your physician to assess any injury, infection or other abnormalities. Type a ccfs are highflow direct shunts between the ica and the cavernous sinus fig.
Imaging findings and outcomes in patients with carotid cavernous. A ct scan showed enlarged superior ophthalmic vein and cavernous sinus on the symptomatic side. The mri scan is an informative, noninvasive alternative to an angiogram that is used to determine the permanence. The most common method of treatment for these lesions is transvenous endovascular embolization via the inferior petrosal sinus or the facial vein. Performing an mri or ct angiogram scan on a patient can help detect the condition early, increasing the chance of a correct diagnosis and no longterm effects as a result. The epub format uses ebook readers, which have several ease of reading features already built in. Stereotactic radiosurgery for dural carotid cavernous. A complementary ct scan is performed if an associated abnormality of the base.
A noncontrast cranial ct scan must be done in order to search skull fractures or intracranial haemorrhages 3. Carotid cavernous fistula is a multiauthored monograph devoted to the. Dural cavernous sinus fistulas dcsfs are benign vascular diseases consisting. Traumatic middle meningeal artery and fistula formation with the.
A carotid cavernous sinus fistula ccf is an arterialvenous fistula between the internal carotid artery and cavernous sinus, and can be classified as either direct or indirect. Examination of magnetic resonance angiography mra source images, in addition to the conventional mra reconstructions, is now also recognised as a useful method of. Carotid cavernous fistula ccf is an abnormal connection between the carotid arterial system and the cs, which may be classified into 4 types. Carotidcavernous fistula an overview sciencedirect topics. For more information or to schedule an appointment, please call 3104238000. Discussion carotid cavernous fistulae represent a direct communication between the arterial flow of the carotid siphon and the venous compartment of the cavernous sinus 1, 2, 3. Imaging diagnosis of dural and direct cavernous carotid. Carotidcavernous fistulae are a specific kind of dural fistula that involves the carotid artery or its branches and a large vein cavernous sinus behind the eye.
Spontaneous resolution of posttraumatic direct carotid. Venous drainage patterns in carotid cavernous fistulas. Because runoff has occurred, carotid preservation remains the treatment of choice. If detected early, the condition can be easily treated with an endoscopic procedure, but if left untreated it can eventually lead to blindness. A carotid cavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull.
Signs and symptoms are related to the compression of structures within the cavernous sinus, including the. May 08, 2020 in the early stages, a carotid cavernous fistula often can be misdiagnosed by doctors. Oct 28, 2015 carotid cavernous fistulas ccfs are abnormal communications between the carotid arterial system and the venous cavernous sinus. Carotid cavernous fistula definition of carotid cavernous. Imaging lesions of the cavernous sinus american journal. Several investigations, including magnetic resonance imaging mri, computed tomography ct, and orbital ultrasound are used to noninvasively screen for carotid cavernous fistula ccf, with variable results. Carotidcavernous fistula ccf is usually a rare complication of severe head injury. Ct scan can depict proptosis, enlargement of the extraocular. The procedure was performed with an 8f guiding catheter cordis, usa. We evaluated drainage patterns of ccfs by digital subtraction angiography dsa and categorized drainage pathways according to their types and etiology. Fractures or the shearing forces of severe head trauma.
The symptoms of the condition can be similar to thyroid eye disease or conjunctivitis. Carotid cavernous fistula ccf is an abnormal communication between the cavernous sinus and the carotid arterial system. Although the book is best suited to those who will be responsible for. Mri of dural carotidcavernous fistulas comparisons with. Ct angiography abdomen, kidneys, extremities cedarssinai. Vascular sequences such as timeofflight are commonly used to evaluate the aneurysms.
When transvenous access is not possible, an alternate approach must be devised. A ccf can be due to a direct connection between the cavernous segment of the internal carotid artery and the cavernous sinus, or a communication between the cavernous sinus, and one or more meningeal branches of the internal carotid artery, external carotid artery or both. The venous drainage of this compartment is directed into the engorged superior ophthalmic vein red. The carotidcavernous fistula ccf is an abnormal arteriovenous communication and its drainage pathways may affect the clinic presentation and change treatment approach. Type b ccfs are dural shunts between meningeal branches of the cavernous ica arising from the meningohypophyseal or ilt trunks and the cavernous sinus fig. Carotidcavernous fistula and carotid artery aneurysm sonoworld. Most of the posttraumatic ccfs are encountered in young male subjects. A three plane localiser must be taken in the beginning to localise and plan the sequences. Injections of the right and left carotid arteries demonstrate a fistula at the posterior aspect of the left cavernous sinus medial compartment pink, supplied by various branches of the left and right mht. Arteriovenous fistulae of the cavernous sinus are rare and difficult to diagnose. Magnetic resonance angiography source images in carotid. We describe a case example with bilateral barrow type b. The fistula was successfully treated angiographically.
An almost complete carotidcavernous fistula demonstrates only minimal runoff to the ipsilateral intracavernous carotid artery territory. This was a prospective cohort study consisting of 60. Final diagnosis mri confirmed the final diagnosis to be a carotid cavernous fistula and a right carotid artery aneurysm. Mri rectoveginal fistula planning mri rv fistula protocols. The fistula may occur spontaneously but usually occurs following. The diagnosis was confirmed by digital subtraction angiography in all four instances. This article is from march 2008 and may contain outdated material. The treatment of a carotid cavernous fistula ccf depends on the severity of the clinical symptoms, its angiographic characteristics, and the risk it presents for intracranial hemorrhage. These arteriovenous av shunts can develop spontaneously, but the overwhelming majority 80% are the result of a traumatic injury to the ica or a branch artery. Increased pressure within the cs seems to be the mainstay of pathophysiology, although arterial steal and increased flow plays an important role. Endovascular treatment strategy for direct carotid cavernous fistulas resulting from rupture of intracavernous carotid aneurysms. Final diagnosis mri confirmed the final diagnosis to be a carotidcavernous fistula and a right carotid artery aneurysm. It also provides an objective method to group the ccfs.
The mri protocol associates coronal thin slices 23 mm on t2 spin echo and t1 spin echo after contrast medium injection covering the cavernous sinuses and orbits, and axial thin slices on t1 spin echo with injection and fat saturation, in some cases completed by axial thin slices on t2 spin echo. Ct angiography and mr angiography in the evaluation of carotid cavernous sinus fistula prior to embolization. May 11, 2020 a magnetic resonance imaging mri scan of the head will be obtained in 6 months. Magnetic resonance imaging mri revealed the dilated left superior ophthalmic vein fig. Carotid cavernous fistulas are abnormal communications between the carotid artery and the cavernous sinus, either directly or via intradural branches of the internal or external carotid arteries. Angiogram shows endovascular embolization achieved complete occlusion of carotid cavernous fistula arrow. To our knowledge, this is the first report of the ct angiographic appearance of carotid cavernous fistulas. Treatment of carotid cavernous fistulas northwestern scholars. The potentially sightrobbing vascular abnormality known as the carotid cavernous sinus fistula ccf can masquerade as conjunctivitis or other common ocular conditions, which diminishes the chance for a speedy diagnosis. The cavernous sinuses were symmetric and normal in size, with slightly increased flow voids in the left cavernous sinus. A caroticocavernous fistula ccf may be due to either a direct connection between the cavernous ica and the cavernous sinus and present acutely, or due to an indirect connection via small branches of the ica, eca, or as in this case both. A carotid cavernous fistula ccf is an abnormal passage between the venous cavernous sinus and the internal carotid artery. These lesions may be classified based on the following.
Endovascular treatment of carotid cavernous sinus fistula. In contrast, indirect fistulas are low flow, often spontaneous, and may have a. A 55yearold woman with a long history of hypertension presented to the hospital with a. Miller, md, an elderly woman with a spontaneous carotidcavernous fistula developed crvo when the clinical symptoms and signs of the patient were otherwise improving. Carotid cavernous fistulas ccf are acquired pathological direct shunts from the cavernous portion of the internal carotid artery ica into the enveloping cavernous sinus fig. Traumatic carotid cavernous fistula accompanying basilar skull fracture. Most often, ccfs are broadly classified as either direct or indirect, on the basis of anatomic features depicted on angiograms. Examination of magnetic resonance angiography mra source images, in addition to the conventional mra reconstructions, is now also recognised as a useful method of detecting ccf. Caroticocavernous fistulas ccf represent abnormal communication between the carotid circulation and the cavernous sinus. Caroticocavernous fistulas ccf represent abnormal communication between the.
Use arteriography to diagnose direct or indirect carotidcavernous fistula. A carotid cavernous sinus fistula is an abnormal connection that forms between a carotid artery in your neck and the network of veins at the back of your eye. Indirect ccfs represent a subset of dural arteriovenous fistulas involving the cavernous sinus, which receive blood flow from meningeal branches of the internal andor external carotid arteries that normally supply the cavernous sinus dura 2, 26. To our knowledge, this is the first report of the ct angiographic appearance of carotidcavernous fistulas. Carotidcavernous fistula may result from the down fracture of the maxilla or the pterygoid osteotomy, thus injuring the internal carotid artery. Dural cavernous sinus fistulas diagnosis and endovascular. Although imaging features of nonvascular cs diseases are most often nonspecific, careful analysis of the adjacent structures. Conventional reconstructed mra did not reveal a fistula. Imaging of the cavernous sinus lesions sciencedirect.
They are postulated to occur secondary to cavernous sinus thrombosis with revascularization and thus. Imaging findings are remarkably similar in both dural cavernous sinus fistulae and carotidcavernous fistulae. Per protocol, he remained flat in bed for 6 hours for femoral artery stasis. Carotid cavernous fistula radiology rsna publications online.
Indirect ccfs tend to present insidiously in postmenopausal women and are commonly misdiagnosed, thus delaying treatment. They are classified into dural cavernous sinus fistulae or direct carotidcavernous fistulae. Despite the similarity of symptoms between both types, a precise diagnosis is essential since. Mri findings in carotidcavernous fistulas include the following 12, 7, 8. Carotid cavernous sinus fistulae are rare, but serious, vascular anomalies which may develop following traumatic injury to the skull base. Diagnosis and management of carotid cavernous fistulas. Endovascular treatment of carotid cavernous fistulae. Ccfs are classified into two main types based on their pathophysiology, direct type a and indirect type bd 1, 2, as shown in figure 1. The carotid cavernous fistula ccf is an abnormal arteriovenous communication and its drainage pathways may affect the clinic presentation and change treatment approach. There was a left supraorbital pulsesynchronous bruit.
An 11monthold female patient presented with symptoms of orbital venous congestion. T1weighted brain mri showed left superior ophthalmic vein sov. Ct scan of the head showed subarachnoid hemorrhage. This article is from june 2005 and may contain outdated material. A carotid cavernous fistula is an abnormal communication between the carotid arterial system and the cavernous sinus. Direct ccf type a is a highflow communication between the ica and the cs that occurs after trauma or secondary to a ruptured aneurysm of the cavernous ica. Ccfs can be classified by anatomy direct or dural, etiology traumatic or spontaneous or blood flow velocity high or low.
Arteriovenous fistula, cavernous sinus, ultrasonography. Type c ccfs are dural shunts between external carotid meningeal branches and the cavernous sinus fig. The mri scan is an informative, noninvasive alternative to an angiogram that is. Cureus transorbital approach for endovascular occlusion. As arterial blood under high pressure enters the cavernous sinus, the normal venous return to the cavernous sinus is impeded and this causes engorgement of the draining veins, manifesting most dramatically as a. A magnetic resonance imaging mri scan of the head will be obtained in 6 months. Carotid cavernous fistula with bilateral thalamic infarct jeremy was suffering from a carotid cavernous fistula an abnormal connection between two blood vessels in his skull which impaired his vision and restricted his ability to. Carotid cavernous fistula, abnormal cs hyperintensity on arterial tof imaging. Young men are at highest risk, as the major cause is head trauma. Ct and mri are the preferred noninvasive imaging techniques in diagnostic approach of ccf. To determine the site and type of carotid cavernous fistula by the means of diagnostic conventional digital subtraction angiography. Abstract a carotid cavernous fistula ccf is an abnormal communication between the venous cavernous sinus and the carotid artery. Treatment of carotid cavernous fistulas request pdf. Anatomically these fistulas can be divided into 2 types, direct and indirect or dural ccf.
Ten patients with dural carotidcavernous fistulas ccfs who presented with ophthalmic. In contrast, indirect fistulas are low flow, often spontaneous, and may have a subtle clinical presentation. Ccf is an abnormal communication between carotid arterial system internal carotid artery ica or external carotid artery eca and cavernous sinus cs fig. Classification of cavernous sinus fistulas csfs and dural. Four cases in which the diagnosis of carotid cavernous fistula was made by using ct angiography are illustrated. Successful coil embolization of the fistula was performed with resolution of the infants. The difference in the blood pressure between the arteries and the veins behind the eye leads to a buildup of blood in a persons eye. Mar 20, 2016 spontaneous carotid cavernous fistulas are classified into the following groups a. Traumatic carotidcavernous fistula of barrow type c is uncommon.
As arterial blood under high pressure enters the cavernous sinus, the normal venous return to the cavernous sinus is impeded and this causes engorgement of the. Carotid cavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. Mark taper foundation imaging center has a team of specialists, led by barry d. Jan 16, 2009 use arteriography to diagnose direct or indirect carotid cavernous fistula. A computed tomography scan ct or cat of your sinuses uses xray technology and advanced computer analysis to create detailed pictures of the sinus. This study compared ct angiography cta, mr angiography mra, and digital subtraction angiography dsa in elucidating the size and location of carotid cavernous sinus fistulas ccfs before embolization treatment. Carotid cavernous fistula may result from the down fracture of the maxilla or the pterygoid osteotomy, thus injuring the internal carotid artery. T1weighted brain mri showed left superior ophthalmic vein sov enlargement fig 1 1. Carotidcavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. A carotidcavernous fistula is a vascular disorder in the cavernous sinus region of the skull.
Ccf represents an abnormal communication from the carotid artery to the cavernous sinus. A carotidcavernous sinus fistula is an abnormal connection that forms between a carotid artery in your neck and the network of veins at the back of your eye. Examination of magnetic resonance angiography mra source images, in addition to the conventional. A ccf represents an abnormal communication between the cavernous sinus and the carotid circulation, either indirectly from eca andor ica branches or directly from the cavernous ica. Indirect lowflow dural shunts between meningeal branches of the ica and the cavernous sinus. The association of carotidcavernous fistulas with crvo has frequently been reported in the literature. Ruptured cavernous sinus aneurysms causing carotid cavernous fistula. Carotidcavernous fistulas ccfs pose an anatomically and physiologically challenging problem for clinicians. Ccf can be traumatic or spontaneous, with the traumatic type being more common, representing 75% of all ccfs.
Advances in the endovascular treatment of direct carotid. Ccfs are classified using the barrow classification. Imaging diagnosis of dural and direct cavernous carotid fistulae. Epileptic seizures induced by a spontaneous carotid cavernous fistula. Imaging findings are remarkably similar in both dural cavernous sinus fistulae and carotidcavernous fistulae, but it is possible to differentiate one type from the other. Carotidcavernous sinus fistula definition of carotid. Management of direct carotidcavernous fistula radiology key.
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