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BACKGROUND: A 49-year-old woman with a history of hypertension presented to the emergency department with right eye redness, proptosis, orbital fullness, and blurry vision. She had initially been diagnosed with an orbital pseudotumor, and the symptoms worsened over a course of steroids. Computed tomography angiography raised concern for a carotid-cavernous fistula (CCF), which was subsequently confirmed by digital subtraction angiography. OBSERVATIONS: She underwent fistula coil embolization via the internal maxillary artery and inferior ophthalmic vein (IOV). At the 2-month follow-up, she reported complete resolution of diplopia, orbital fullness, and proptosis. An ophthalmology examination revealed normal visual fields bilaterally. LESSONS: CCF embolization is rarely performed through the IOV, with only 5 reported cases in the literature. This case demonstrates that the procedure can be easily performed if the anatomy is favorable over the superior ophthalmic vein, with the illustration of good cosmetic outcomes. https://thejns.org/doi/10.3171/CASE24183.

A 24-year-old male was admitted with progressive cervical hypesthesia, tetraparesis, dyspnea, and a history of craniofacial fracture. Spinal magnetic resonance imaging (MRI) showed brainstem edema extending to the thoracic spine with multiple prominent perimedullary vascular structures. Cerebral digital-substraction angiography revealed Barrow type A carotid-cavernous fistula. Total occlusion with preservation of internal carotid artery flow was achieved using 1 detachable balloon and 6 coils. Postoperatively, immediate respiratory recovery, gradual extremities strength improvement, and right abducens nerve palsy were found. One month follow-up cervical MRI showed good recovery of spinal cord edema and perimedullary veins.

Direct carotid cavernous fistula is an abnormal arterio-venous connection from the carotid artery to the cavernous sinus (CS), resulting in high-pressure arterial blood entering the low-pressure venous CS. Most often, it occurs posttrauma and presents with ipsilateral orbital signs. In this report, we describe the case of a 54-year-old man, who presented with a late-onset right-sided red eye and diplopia following contralateral (left sided) orbital trauma (road traffic accident 7 months ago). Ocular examination revealed signs of Lateral rectus palsy, axial proptosis, and elevated intraocular pressure with dilated episcleral vessels in the right eye. Clinical findings were consistent with the diagnosis of right-sided direct CCF. To our surprise, digital subtraction angiogram revealed a left CCF with prominence of signs on the contralateral side. He underwent near-total endovascular coiling of the fistula, with initial aggravation of symptoms followed by near-total resolution.

Carotid-cavernous fistula (CCF) is a rare condition involving an abnormal communication between the carotid artery and the cavernous sinus. We present a unique case of posttraumatic unilateral CCF initially misdiagnosed as a corneal melt with iris prolapse and orbital cellulitis. The patient, a 25-year-old male, experienced swelling, bleeding, and sudden vision loss in the affected eye following a fall. Imaging confirmed a direct CCF, and the patient underwent endovascular coiling, evisceration, and prosthetic replacement. Partial loss of levator palpebrae superioris muscle function was observed postprocedure. This case underscores the diagnostic challenge of CCF and highlights the significance of early and accurate diagnosis for appropriate management.

Abstract Background Owing to their peculiar location, cavernous sinuses communicate with numerous head and neck structures via fissures and foramen which provide an easy access for pathologies to traverse to and from the cavernous sinuses to these vital structures. On routine brain imaging, diseases involving the cavernous sinuses can be easily missed if we are not vigilant to examine cavernous sinuses using dedicated thin sections of sellar and parasellar region. Main body of the abstract The various pathologic conditions involving cavernous sinuses either primarily or secondarily include neoplasms, vascular conditions, cystic/fat-containing lesions and infective/inflammatory conditions. Due to considerable overlap in clinical symptoms of numerous diseases affecting cavernous sinuses, timely and effective imaging evaluation of cavernous sinuses using multimodality approach with dedicated imaging sequences can help in formulating a clinically relevant differential diagnosis and alter patient management. Thin T1- and T2-weighted axial and coronal images with appropriately timed MR angiography and venography should be performed for diagnosis of cavernous sinus pathologies and delineation of pathologies arising from closely placed neurovascular structures in this region of middle cranial fossa. In this review article, we aim to discuss how to best image the cavernous sinuses for detection of cavernous sinus pathologies and imaging appearance of various pathologies involving cavernous sinuses. Conclusion Cavernous sinuses form an important pathway for spread of numerous pathologies to and from the intracranial compartment to nearby vital structures. A variety of conditions can affect these small paired venous structures including benign and malignant neoplasms, vascular lesions, and infective/inflammatory pathologies. It is therefore important that besides routine brain imaging, dedicated thin axial and coronal images along with contrast-enhanced imaging should be performed for diagnosis of cavernous sinus pathologies.

Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus, which is most commonly caused by trauma. Due to its high-flow nature and aggressive clinical course, spontaneous resolution of CCF is rare, making endovascular embolization necessary. This procedure aims to prevent potential vision loss, emphasizing the importance of timely intervention to preserve visual function. We report a case of Barrow type A carotid-cavernous fistula which resolved spontaneously. A 42-year-old male was referred to Emergency Room with a chief complaint of seizure 3 days before admission. The seizure was both arm stiff and jerking, the eyes gazing upward, bitten tongue, foamy mouth, no bed wetting. Meanwhile, the patient was unconscious during and after the seizure. Regarding the medical history, the patient experienced head trauma 8 months ago due to a traffic accident. Additionally, the patient reported symptoms of redness, swelling, double vision, and inability to look to the right eye. Initial cerebral angiography was performed, reporting a carotid-cavernous fistula of Barrow type A. Further endovascular treatment could not be carried out, but a second cerebral angiography was conducted after a year, demonstrating spontaneous thrombosis of the carotid-cavernous fistula of Barrow type A. CCF were classified by Barrow et al. into types A, B, C, and D. It has been proposed that spontaneous resolution of CCF Barrow type A may result from thrombosis of the cavernous sinus.

Carotid-cavernous fistula (CCF) is a rare condition. However, it should be suspected when there are traumatic facial fractures, because if not diagnosed, it can lead to permanent damage such as blindness. Traumatic CCF often presents delayed symptoms, and delayed diagnosis without prompt treatment can lead to permanent injuries in optic and cranial nerves III, IV, V, and VI as well as intracranial hemorrhage. The routine initial modality for patients with suspected facial bone fractures is noncontrast computed tomography (CT) to identify any fracture lines and check for intracranial hemorrhage. We report a post-traumatic CCF case with a 4-day symptom delay, where left superior ophthalmic vein (SOV) enlargement was observed on the routine noncontrast facial CT with ipsilateral orbital wall fracture. When the patient first presented to the emergency room (ER), we did not detect vein enlargement on CT. Afterwards, the patient developed delayed symptoms of CCF and was readmitted to the ER. When we reanalyzed the first CT scan, an enlarged SOV was confirmed. The diagnosis was confirmed via magnetic resonance imaging angiography, and the patient was successfully treated with embolization of the fistula. Thus, we recommend reviewing ophthalmic vein enlargement that is readily identifiable through noncontrast CT for patients injured by craniofacial trauma to suspect the presence of delayed CCF at their initial presentation.

Background: Owing to their peculiar location, cavernous sinuses communicate with numerous head and neck structures via fissures and foramen which provide an easy access for pathologies to traverse to and from the cavernous sinuses to these vital structures. On routine brain imaging, diseases involving the cavernous sinuses can be easily missed if we are not vigilant to examine cavernous sinuses using dedicated thin sections of sellar and parasellar region. The various pathologic conditions involving cavernous sinuses either primarily or secondarily include neoplasms, vascular conditions, cystic/fat-containing lesions and infective/inflammatory conditions. Due to considerable overlap in clinical symptoms of numerous diseases affecting cavernous sinuses, timely and effective imaging evaluation of cavernous sinuses using multimodality approach with dedicated imaging sequences can help in formulating a clinically relevant differential diagnosis and alter patient management. Thin T1- and T2-weighted axial and coronal images with appropriately timed MR angiography and venography should be performed for diagnosis of cavernous sinus pathologies and delineation of pathologies arising from closely placed neurovascular structures in this region of middle cranial fossa. In this review article, we aim to discuss how to best image the cavernous sinuses for detection of cavernous sinus pathologies and imaging appearance of various pathologies involving cavernous sinuses. Conclusion: Cavernous sinuses form an important pathway for spread of numerous pathologies to and from the intracranial compartment to nearby vital structures. A variety of conditions can affect these small paired venous structures including benign and malignant neoplasms, vascular lesions, and infective/inflammatory pathologies. It is therefore important that besides routine brain imaging, dedicated thin axial and coronal images along with contrast-enhanced imaging should be performed for diagnosis of cavernous sinus pathologies. [ABSTRACT FROM AUTHOR]

Carotid-cavernous fistula (CCF) is a rare condition involving an abnormal communication between the carotid artery and the cavernous sinus. We present a unique case of posttraumatic unilateral CCF initially misdiagnosed as a corneal melt with iris prolapse and orbital cellulitis. The patient, a 25-year-old male, experienced swelling, bleeding, and sudden vision loss in the affected eye following a fall. Imaging confirmed a direct CCF, and the patient underwent endovascular coiling, evisceration, and prosthetic replacement. Partial loss of levator palpebrae superioris muscle function was observed postprocedure. This case underscores the diagnostic challenge of CCF and highlights the significance of early and accurate diagnosis for appropriate management. [ABSTRACT FROM AUTHOR]

Direct carotid cavernous fistula is an abnormal arterio-venous connection from the carotid artery to the cavernous sinus (CS), resulting in high-pressure arterial blood entering the low-pressure venous CS. Most often, it occurs posttrauma and presents with ipsilateral orbital signs. In this report, we describe the case of a 54-year-old man, who presented with a late-onset right-sided red eye and diplopia following contralateral (left sided) orbital trauma (road traffic accident 7 months ago). Ocular examination revealed signs of Lateral rectus palsy, axial proptosis, and elevated intraocular pressure with dilated episcleral vessels in the right eye. Clinical findings were consistent with the diagnosis of right-sided direct CCF. To our surprise, digital subtraction angiogram revealed a left CCF with prominence of signs on the contralateral side. He underwent near-total endovascular coiling of the fistula, with initial aggravation of symptoms followed by near-total resolution. [ABSTRACT FROM AUTHOR]

Purpose: Spontaneous direct carotid-cavernous fistula (CCF) are usually caused by a ruptured carotid cavernous aneurysm. We studied treatment of spontaneous direct CCFs in a single-center cohort of a high-volume tertiary referral center, reporting anatomical details, technical approaches of treatment, and outcomes. Methods: Adult patients with a spontaneous direct CCF treated between 2010–2022 with follow-up MRI and/or DSA imaging available were retrospectively analyzed. We studied age, sex, clinical presentation, angiographic findings, treatment techniques, outcomes, and complications. Results: Out of 80 patients with CCFs, twelve patients were treated for a non-traumatic direct CCF (15%) in 13 sessions. Median age was 65 years. Two patients had an underlying connective tissue disorder. In 10 cases, the direct CCF was caused by a ruptured cavernous carotid aneurysm. The direct CCFs were treated by endovascular transarterial embolization (10 cases), transvenous embolization (1 case), or surgery (1 case). Selective closure of the shunt was possible in 10 patients. Two patients were treated with parent vessel occlusion (PVO; one endovascular; one surgical, with bypass). Complications occurred in 2 / 12 patients (17%), with permanent morbidity in two patients (17%): trigeminal neuralgia after PVO and new infarct after surgical PVO and bypass. Selective closure of CCF resulted in no morbidity. There was no mortality in our series. Conclusion: Spontaneous direct CCFs are caused by rupture of a cavernous carotid aneurysm in most cases. Selective closure of the shunt, usually feasible transarterially with coils, achieves good results. Reconstructive endovascular techniques are preferred to minimize treatment related neurological complications. [ABSTRACT FROM AUTHOR]

Carotid-cavernous fistula (CCF) is a rare condition. However, it should be suspected when there are traumatic facial fractures, because if not diagnosed, it can lead to permanent damage such as blindness. Traumatic CCF often presents delayed symptoms, and delayed diagnosis without prompt treatment can lead to permanent injuries in optic and cranial nerves III, IV, V, and VI as well as intracranial hemorrhage. The routine initial modality for patients with suspected facial bone fractures is noncontrast computed tomography (CT) to identify any fracture lines and check for intracranial hemorrhage. We report a post-traumatic CCF case with a 4-day symptom delay, where left superior ophthalmic vein (SOV) enlargement was observed on the routine noncontrast facial CT with ipsilateral orbital wall fracture. When the patient first presented to the emergency room (ER), we did not detect vein enlargement on CT. Afterwards, the patient developed delayed symptoms of CCF and was readmitted to the ER. When we reanalyzed the first CT scan, an enlarged SOV was confirmed. The diagnosis was confirmed via magnetic resonance imaging angiography, and the patient was successfully treated with embolization of the fistula. Thus, we recommend reviewing ophthalmic vein enlargement that is readily identifiable through noncontrast CT for patients injured by craniofacial trauma to suspect the presence of delayed CCF at their initial presentation. [ABSTRACT FROM AUTHOR]

Objectives: To describe the clinical presentation of carotico-cavernous fistula (CCF) and outcomes of endovascular balloon embolization in a tertiary care center in a developing country. Materials and Methods: This retrospective interventional case series included 18 patients who underwent endovascular balloon embolization from 2019 to 2022 at Lahore General Hospital in Lahore, Pakistan. The analyzed data consisted of age, gender, cause and type of CCF, clinical presentation, diagnostic technique used, intervention, and the results of two-month follow-up. Patients with incomplete records and coil embolization were excluded. Digital subtraction angiography was done in all cases followed by endo-arterial balloon embolization. Procedures were carried out under general anesthesia via femoral artery approach. A single balloon was sufficient to close the fistula in all cases. Results: There were 18 patients who met the inclusion criteria. Sixteen patients had direct CCF, and the mean age of the patients was 27.2±12.6 years. The commonest cause of CCF was trauma, and the mean time of presentation after trauma was 7.89±7.19 months. The male-to-female ratio was 8:1. Preoperative visual acuity was worse than 6/60 in 8 patients, between 6/60 and 6/18 in 7 patients, and better than 6/18 in 3 patients. The mean intraocular pressure was 16.06±3.37 mmHg preoperatively and 14.83±3.49 mmHg postoperatively (p=0.005). Endovascular embolization was successful in 15 patients (83.3%). One patient developed epidural hematoma as a complication of the procedure, which was drained later. There was no mortality related with the procedure. Conclusion: Balloon embolization via the femoral artery is an efficient technique in direct as well as indirect CCF. It is safe and simple with very good results if performed in a timely manner.

Objectives: To describe the clinical presentation of carotico-cavernous fistula (CCF) and outcomes of endovascular balloon embolization in a tertiary care center in a developing country. Materials and Methods: This retrospective interventional case series included 18 patients who underwent endovascular balloon embolization from 2019 to 2022 at Lahore General Hospital in Lahore, Pakistan. The analyzed data consisted of age, gender, cause and type of CCF, clinical presentation, diagnostic technique used, intervention, and the results of two-month follow-up. Patients with incomplete records and coil embolization were excluded. Digital subtraction angiography was done in all cases followed by endo-arterial balloon embolization. Procedures were carried out under general anesthesia via femoral artery approach. A single balloon was sufficient to close the fistula in all cases. Results: There were 18 patients who met the inclusion criteria. Sixteen patients had direct CCF, and the mean age of the patients was 27.2±12.6 years. The commonest cause of CCF was trauma, and the mean time of presentation after trauma was 7.89±7.19 months. The male-to-female ratio was 8:1. Preoperative visual acuity was worse than 6/60 in 8 patients, between 6/60 and 6/18 in 7 patients, and better than 6/18 in 3 patients. The mean intraocular pressure was 16.06±3.37 mmHg preoperatively and 14.83±3.49 mmHg postoperatively (p=0.005). Endovascular embolization was successful in 15 patients (83.3%). One patient developed epidural hematoma as a complication of the procedure, which was drained later. There was no mortality related with the procedure. Conclusion: Balloon embolization via the femoral artery is an efficient technique in direct as well as indirect CCF. It is safe and simple with very good results if performed in a timely manner. [ABSTRACT FROM AUTHOR]

The three classic symptoms of carotid cavernous fistula (CCF) are pulsating exophthalmos, bruit and conjunctival chemosis. Here, we present a clinical case of isolated abducens nerve palsy due to a high-flow CCF in an 84-year-old woman, without the typical congestive orbito-ocular features. It was a diagnostic challenge because, for patients older than 50 years with cardiovascular risk factors, ischaemic mononeuropathy is the most frequent aetiology. This case illustrates the least common type of CCF that can be easily misdiagnosed. Physicians should consider fistula as a possible diagnosis in a patient with isolated abducens nerve palsy even without the classic triad. [ABSTRACT FROM AUTHOR]

Background and Purpose: To present the first study analyzing the clinical and radiological course of carotid‐cavernous fistulas (CCFs) following incomplete embolization. The study compares magnetic resonance angiography (MRA) to plain angiography (digital subtraction angiography [DSA]) and investigates the long‐term ophthalmological impact of residual fistula. Methods: Fistulas classified as partially embolized after the last endovascular treatment were prospectively followed with DSA, MRA, and ophthalmological examination. Both direct and indirect CCFs were included. Results: Twenty‐one CCFs were included in the study. Nine (43%) fistulas were direct and 12 (57%) were indirect. A favorable clinical outcome of modified Rankin scale ≤2 was recorded in 19 (90%) patients at the last follow‐up. Postinterventional ophthalmologic examinations in 16 patients revealed no negative effects of residual fistulas; five remaining patients refused to undergo further examination. Spontaneous thrombosis and complete occlusion of the CCF were demonstrated in 90% of patients, with a mean time to occlusion of 5.7 ± 4.7 months. Fourteen (66%) patients completed the full imaging follow‐up (MRA and DSA). In 21% of these cases, discrepancy between the two imaging modalities was observed—MRA failed to detect persistent fistulas identified by DSA. Conclusions: The goal of CCF treatment is safe and complete embolization. However, if adequate flow reduction is achieved, both direct and indirect CCFs tend to spontaneously thrombose. Residual flow does not result in ophthalmological deterioration until the fistula is completely closed. MRA may not be sufficiently sensitive to detect residues of fistulas including cortical venous drainage. Therefore, complete CCF closure should be confirmed through DSA. [ABSTRACT FROM AUTHOR]

We present a case of carotid-cavernous fistula (CCF) in a 52-year-old female patient who was urgently referred for surgical treatment of a left-sided orbital phlegmon. On the 62nd day after a traumatic brain injury, the patient revealed a visual impairment of the left eye, which was noticeably red and showed a moderate protrusion. The patient’s left orbit was urgently opened and drained.She was undergoing an anti-inflammatory therapy and showed a positive dynamic of the disease, whilst on the 5th day after the procedure, the patient started feeling pain in the left eye and noise in the head. The data of ultrasound examination of the orbit and duplex scanning were largely consistent with a severe massive inflammatory infiltration of the retrobulbar tissue with hypervascularization (the orbital phlegmon could not be excluded). Only a selective computed tomography with angiography helped establish the final diagnosis: arteriovenous malformation in the projection of the supra-sphenoid section of the left internal carotid artery, with post-traumatic CCF on the left. After surgery (endovascular embolization of the CCF), a positive result was observed: with a positive result — no injection or pain in the left eye, exophthalmos gradually regressed. Yet the visual acuity of the left eye was 0.03 due to an atrophy of the optic nerve.Conclusion. The ophthalmologists must be on the alert in cases of unilateral exophthalmos with a history of blunt head trauma, since neuro-ophthalmic symptoms are crucial in clarifying the indications for a prompt implementation of the only surgical treatment effective for this pathology, i.e. endovascular embolization.

A carotid-cavernous fistula is a rare abnormal communication between carotid vasculature and the cavernous sinus. Development of a carotid-cavernous fistula often results from trauma, but may be spontaneous in the setting of predisposing risk factors. Suspicion for a spontaneous fistula is understandably low on routine non-contrast imaging. In this article, we present a case of a carotid-cavernous fistula initially presenting with the potentially underrecognized imaging manifestation of diffuse pituitary enlargement identified on a non-contrast CT, later revealed to be due to the presence of the fistula.

Rationale: Pseudoaneurysms of the ophthalmic segment of the internal carotid artery (ICA) caused by trauma are rare in clinical practice, and concomitant carotid cavernous fistula (CCF) is even rarer, especially when the rupture of the pseudoaneurysm leads to recurrent subarachnoid hemorrhage (SAH), which has not been reported in the literature to date. Here, we report a case of traumatic pseudoaneurysm of the ophthalmic segment of the internal carotid artery with CCF clinically presenting as recurrent SAH.Patient concerns: A 26-year-old young man sustained a craniocerebral injury as a result of a motorcycle accident.Diagnoses: After the 16th day after the trauma, the patient again presented with neurologic symptoms such as headache and dizziness. Computed tomography (CT) scan of the brain showed acute SAH along the lateral interhemispheric fissure and an intracerebral hematoma in the saddle CT angiography and digital subtraction angiography of the brain showed a pseudoaneurysm of the ophthalmic segment of the internal carotid artery with CCF.Interventions: Since the ophthalmic artery pseudoaneurysm was in the same internal carotid artery as the CCF and the location of the rupture was different, endovascular treatment was performed by the intra-arterial route using stent-assisted techniques in combination with coils.Outcomes: After treatment by stent-assisted technique combined with spring-coil embolic material, the rupture of the pseudoaneurysmal sac and CCF was sufficiently blocked, and the lesion completely regressed immediately after endovascular treatment.Lessons: Pseudoaneurysms of the ophthalmic artery with CCF rarely occur after head trauma and are mainly due to vascular lacerations following skull base fractures. Pseudoaneurysms of the ophthalmic artery may present as SAH due to intracranial rupture with concomitant fracture of the upper wall; therefore, early diagnosis using CT or magnetic resonance angiography is necessary, as well as appropriate treatment by understanding the mechanism of the disease.

Carotid-cavernous fistulas are rare entity with incidence of less than 1%, refers to abnormal connections between the carotid artery and cavernous sinus. Indirect types usually occur in elderly female patients and can resolve spontaneously with conservative management like external manual compression of the carotid artery. We report a case of 65-year-old female who presented with complaints of redness, proptosis, chemosis, headache and ophthalmoplegia in her right eye. Digital subtraction angiography revealed Barrow type B indirect carotid-cavernous fistulas. External manual carotid compression was done after which her symptoms improved significantly. Thus, indirect type carotid-cavernous fistulas can occur spontaneously and could be a sight threatening condition especially in elderly females but can resolve with conservative management.

Although infrequent, occurrences of internal carotid artery (ICA) injuries during transnasal procedures can potentially lead to severe neurological deficits or even prove fatal. We present a case of a 54 years old male patient who suffered an iatrogenic ICA lesion resulting in a pseudo-aneurysm and direct carotid-cavernous fistula after paranasal sinuses surgery. Successful multirdisciplinary treatment included flow diversion, transsphenoidal surgery and embolization of a carotid-cavernous fistula.A sealing of injured ICA wall and complete occlusion of carotid cavernous fistula led to the patient's discharged without any neurological deficits.ICA injury during transnasal surgery is a rare but dangerous and potentially life-threatening complication necessitating multidisciplinary approach and management in a specialized center.

Purpose: Carotid-cavernous fistulas (CCFs) are often underdiagnosed or misdiagnosed. In polytraumatized patients, the focus is primarily on treating potentially life-threatening conditions such as increased intracranial pressure and hemorrhages. This case report aims to identify common diagnostic mistakes in rare pathologies. Objective: We present a case of a young female patient who was admitted to the emergency room after a motorbike accident. The patient's vital parameters were successfully stabilized, and she spent approximately four weeks in the ICU and neurosurgical ward. The patient exhibited limited communication, ophthalmoplegia, and a swollen, red left eye. After four weeks, the patient's parents initiated admission to our department due to the suspicious red swollen eye. Angiography revealed a complete rupture of the internal carotid artery (ICA) into the cavernous sinus, and occlusion of the ICA showed significant improvement in the eye edema and the patient's mental state. Two days later, the patient was able to communicate with complex sentences. Three months after the occlusion, the patient showed positive progress, posting dancing videos on TikTok. Conclusion and Importance: A carotid-cavernous fistula presenting with a red swollen eye can be misdiagnosed as retrobulbar hematoma or conjunctivitis. Failure to recognize and treat it promptly can lead to severe morbidity.

Background 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. Methods 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). Results 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. Conclusion 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

We describe our rescue technique for direct puncture of the inferior ophthalmic vein (IOV) for transvenous access of a direct, high-flow carotid-cavernous fistula (CCF). The CCF was caused by rupture of a large internal carotid artery aneurysm. Aneurysm and fistula embolization solely via the transarterial approach did not appear promising due to partial aneurysm thrombosis. Also, transvenous access via the facial vein failed due to extensive vessel tortuosity. Instead, the engorged and arterialized IOV was accessed by direct puncture with an 18-gauge venous cannula. After a small skin incision of the medial aspect of the lower eyelid and further transseptal puncture, the cannula was advanced stepwise between the maxillary bone and the bulbus oculi and below the medial rectus muscle to the IOV under repeated biplane roadmap guidance in 2 planes. Thereafter, the fistula and the aneurysm dome could be embolized with coils via a low-profile microcatheter. Hereby, a protective flow diverter was implanted via the arterial route into the internal carotid artery to seal the parent artery, prevent coil protrusion, and ensure permanent aneurysm occlusion. At 1-month follow-up, the aneurysm and CCF were completely occluded. Direct puncture of the IOV represents a feasible and minimally invasive approach for venous CCF access. The proposed method needs to be validated by further reports. [ABSTRACT FROM AUTHOR]

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BackgroundThe development of carotid-cavernous fistulas (CCFs) during surgical recanalization of chronic internal carotid artery occlusion (ICAO) may be secondary to severe ICA dissection rather than a focal tear of the cavernous ICA seen in typical traumatic CCFs. The purpose of this study is to investigate the causal relationship between the CCFs and severe ICA dissections and to characterize technical outcomes after treatment with stenting.MethodsFive patients underwent treatment with self-expanding stents due to intraprocedural CCF and ICA dissection following surgical removal of ICAO plaque. The stents were telescopically placed via true channel of the dissection. Safety of the procedure was evaluated with 30-day stroke and death rate. Procedural success was determined by the efficacy of CCF obliteration and ICAO recanalization with angiography.ResultsAll CCFs were associated with spiral and long segmental dissection from the cervical to cavernous ICA. After stenting, successful dissection reconstruction with TICI 3 was achieved in all patients, with complete (n = 4) or partial CCF (n = 1) obliteration. No patient had CCF syndrome, stroke, or death during follow-up of 6 to 37 months; but one patient had pulsatile tinnitus, which resolved 1 year later. Angiography at 6 to 24 months demonstrated CCF obliteration in all 5 patients and durable ICA patency in 4 patients.ConclusionsIntraprocedural CCFs with spiral and cervical-to-cavernous ICA dissection during ICAO surgery are dissection-related because of successful obliteration after stenting for dissection reconstruction. Self-expanding stenting through true channel of the dissection, serving as implanting stent-autograft, may be an optimal therapy for the atypical CCF complication from ICAO surgery.

Dural arteriovenous fistulas involving the cavernous sinus can lead to orbital pain, vision loss and, in the setting of associated cortical venous reflux, intracranial hemorrhage. The treatment of dural arteriovenous fistulas has primarily become the role of the endovascular surgeon. The venous anatomy surrounding the cavernous sinus and venous sinus thrombosis that is often associated with these fistulas contributes to the complexity of these interventions. The current report gives a detailed description of the alternate endovascular routes to the cavernous sinus based on a single center's experience as well as a literature review supporting each approach. A comprehensive understanding of the anatomy and approaches to the cavernous sinus available to the endovascular surgeon is vital to the successful treatment of this condition.

Dural arteriovenous fistulas (DAVFs) are abnormal communications between meningeal arteries and dural venous sinuses and/or cortical veins. Although many fistulas are benign and do not require treatment, some may carry a significant risk of bleeding or cause symptoms and warrant treatment. This review provides a review of various aspects of intracranial DAVFs including epidemiology, pathophysiology, clinical presentation, imaging characteristics, classification, natural history, and management options. By exploring these topics, we aim to enhance understanding of this condition and facilitate patient care. [ABSTRACT FROM AUTHOR]

A painful isolated third nerve palsy is an uncommon presenting sign of a carotid-cavernous fistula (CCF). It mostly occurs in dural CCFs with posterior drainage into the petrosal sinuses. We present a case of a 50-year-old woman who developed acute right periorbital facial pain in the territory of the first branch of the right trigeminal nerve and was noted to have a right dilated unreactive pupil with very subtle right ptosis. She was subsequently diagnosed with a posteriorly draining dural CCF. [ABSTRACT FROM AUTHOR]

Introduction: The carotid-cavernous fistula (CCF) is a pathological communication between an artery and a venous sinus or meningeal veins. Direct arterial blood flow to the veins leads to specific pathophysiological changes and associated with them clinical manifestations, which vary from a benign course with spontaneous remission to a fatal outcome due to cerebral hemorrhage. The treatment of CCF is complex (conservative, endovascular - transarterial or transvenous embolization, surgical, radiosurgical) and, in higher-flow fistulas, is associated with a high risk of recurrence. Conventional angiography, CT angiography, MRI angiography, which are invasive, time-consuming and associated with additional risk studies, are standardly used to monitor the treatment result. Aim: In the present report, we would like to present the capabilities of color-coded duplex sonography (CCDS) as a non-invasive, convenient, rapid, and effective method for assessing CCF in outpatient settings. Material and methods: We present a clinical case of a 40-year-old female patient with complaints of conjunctival injection, eye edema, double vision, nausea and vomiting, progressively worsening after a 1-month-old trauma (traffic accident - being hit by a tram as a pedestrian). Initially, the patient was hospitalized as an emergency and treated conservatively: skull base fracture; subarachnoid hemorrhage on the left fronto-temporo-parietal and right frontal areas; intracerebral hemorrhage in the left frontal cranial fossa; subdural hematoma on the left temporo-occipital region; fracture of the left humerus proximally and left processus mastoideus. Due to these complaints the patient was hospitalized in the Neurosurgery clinic at Acibadem City Clinic MHAT Tokuda for imaging and subsequent treatment. Results: The performed CT and MRI angiographies showed the presence of CCF on the left in the area of the C4 segment of the left ICA with high arterial flow (type I Barrow, Cognard II). The patient underwent endovascular implantation of a flow diverter. In the course of follow-up by CCDS, persistence of arterial blood flow in the ophthalmic veins and progressively rising intraocular pressure (monitored by an ophthalmologist) associated with a high risk of vision loss and additional neurological deterioration were found, for which the patient underwent a secondstage coil-embolization and implantation of a second flow diverter. As part of the pre- and post-procedural assessment of the AV fistula, a transophthalmic CCDS blood flow study in the superior ophthalmic vein was used. This finding was confirmed by the conventional and MRI angiograms performed during the follow-up. Conclusions: CCDS is an effective and easy way to adequately assess hemodynamics in some cases of CCF. [ABSTRACT FROM AUTHOR]

Traumatic pseudoaneurysms of the supraclinoid internal carotid artery (ICA) are uncommon, particularly associated with carotid-cavernous fistulas (CCF) or multiple traumatic aneurysms. This report describes a patient with a ruptured left ICA dissecting pseudoaneurysm that caused a direct CCF and a right anterior cerebral artery (ACA) pseudoaneurysm. To eliminate the aneurysm and fistula, we followed the universal bypass strategy by performing an ICA trapping with high-flow bypass, followed by an ACA trapping with A3-A3 side-to-side bypass. Herein, we report the first successful surgical trapping and revascularization of supraclinoid ICA pseudoaneurysm associated with a direct carotid-cavernous fistula. [ABSTRACT FROM AUTHOR]

Direct carotid-cavernous fistulas are a rare complication of craniofacial trauma that often presents with proptosis, chemosis, and other visual symptoms. Disruption of blood flow from a carotid-cavernous fistula can cause cortical and cranial nerve ischemia which requires emergent intervention. Upon clinical suspicion of a carotid-cavernous fistula, patients should undergo computed tomography angiography (CTA) or magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) if no other etiology is suspected. We present a case of a middle-aged patient with a gunshot wound in the posterior pharynx that resulted in a direct carotid-cavernous fistula of the left internal carotid artery.

Abstract Background Carotid-cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system and exhibits typical symptoms of red eye, diplopia, blurred vision, headache, and murmur. However, the symptoms for CCF may vary and can lead to misdiagnosis. IOP pulsations provide a hint leading to suspicion of CCF. We report three cases related to CCF differential diagnosis: two cases of CCF patients and one case of conjunctivitis with corkscrew conjunctival vessels. Case presentation The case 1 patient, with a typical unilateral CCF, exhibited significant IOP pulsation in Goldmann tonometry measurements in the affected eye. The case 2 patient did not show typical symptoms of CCF except asymmetric upper eyelid swelling (right > left). In clinical evaluation, IOP elevation in the right eye and IOP pulsation in both eyes were noted. Based on radiology, the patient was diagnosed with bilateral CCF. The case 3 patient was referred to our institution for differential diagnosis of CCF. The patient had corkscrew conjunctival vessels in both eyes, which had appeared after he had been revived through CPR (cardiopulmonary resuscitation) 25 years prior. IOP pulsation was not observed in Goldmann tonometry. Radiology test result for arterio-venous fistula was negative in the case 3 patient. Conclusion For diagnosis of CCF, IOP pulsation by Goldmann applanation tonometry exhibits a good correlation with the disease in our cases and provides useful diagnostic clues.

Patients with neurovascular disorders sometimes approach the ophthalmologists with mild ophthalmic clinical features such as conjunctival congestion, slowly progressive proptosis, lateral rectus palsies and at other times with ophthalmic emergencies like sudden increase in proptosis, ophthalmoplegia, diplopia, and ptosis before the onset of neurological manifestations which may be life-threatening if not detected in time. The aim of this article is to focus on ophthalmic manifestations of neurovascular emergencies and role of ophthalmologists in its management. In this communication, to make the ophthalmologist aware of clinical presentations, the imaging modality of choice, diagnostic features, medical and interventional treatments. We have searched PubMed, Web of Science, Google Scholar and reviewed some of the commonly encountered neurovascular emergencies with ocular manifestations such as carotid-cavernous fistula, cerebral venous sinus thrombosis, cerebral artery aneurysms, arterio-venous malformations.

This case report describes a rare event of an undiagnosed bilateral carotid-cavernous fistula manifesting as intraoperative suprachoroidal hemorrhage during cataract surgery Objective: To report a rare case of suprachoroidal hemorrhage during phacoemulsification in a patient with bilateral carotid-cavernous fistula. Method: Case report. Result: A 76-year-old woman with underlying hypertension presented left eye poor vision due to an underlying dense cataract. Her initial preoperative assessment was uneventful, and she underwent phacoemulsification. During epinucleus removal, there was sudden, unexpected anterior chamber shallowing, resulting in posterior capsule rupture. While the surgeon extended the wound to facilitate epinucleus removal, there was a further decrease of red reflex, followed by hardening of the globe, indicating a suprachoroidal hemorrhage. The corneal wound was opposed swiftly without an intraocular lens. Further evaluation after that revealed the patient had a chronic headache for several years, and ocular examination showed bilateral esophoria. A computed tomography demonstrated features suggestive of bilateral carotid-cavernous fistula, which was confirmed with computed tomography angiography later. Conclusion: Patients with carotid-cavernous fistula have elevated episcleral venous pressure and vortex venous pressure. Sudden decompression of the globe in these patients predisposes them to higher suprachoroidal hemorrhage risk, although this condition is generally rare in phacoemulsification. [ABSTRACT FROM AUTHOR]

This report includes a case of a 65-year-old woman presenting with a spontaneous dural carotid-cavernous fistula. Biomicroscopic examination of the anterior segment showed significant conjunctival chemosis, dilatation of the episcleral vessels, narrow anterior chamber, and a proptosis of the right eye, whereas the fellow eye was unremarkable. Retinal examination revealed an impaired arteriovenous ratio (A/V) from 1–4 to 1–2 and two extensive cotton exudates. An ultrasound scan (US) demonstrated congestion of the upper ophthalmic vein. Selective brain angiography through right femoral catheterization revealed a dural fistula of the wall of the cavernous right sinus. The patient underwent surgery on the superior ophthalmic vein and insertion of a micro-catheter in the cavernous sinus under CT guidance. Furthermore, a trans-femoral catheter was placed in the carotid artery on the same side as the fistula to allow arteriographic controls after micro coil positioning and embolization. Angiographic follow-up immediately after positioning the coils showed the occluded fistula and a regular flow circulation between the internal and the external carotid arteries. After treatment, the patient presented a complete resolution of symptoms. Conservative management is effective and safe in treating patients with carotid-cavernous fistula and mild clinical features because of a good chance of spontaneous or secondary thrombosis after arteriographic occlusion. [ABSTRACT FROM AUTHOR]

A 24-year-old male was admitted with progressive cervical hypesthesia, tetraparesis, dyspnea, and a history of craniofacial fracture. Spinal magnetic resonance imaging (MRI) showed brainstem edema extending to the thoracic spine with multiple prominent perimedullary vascular structures. Cerebral digital-substraction angiography revealed Barrow type A carotid-cavernous fistula. Total occlusion with preservation of internal carotid artery flow was achieved using 1 detachable balloon and 6 coils. Postoperatively, immediate respiratory recovery, gradual extremities strength improvement, and right abducens nerve palsy were found. One month follow-up cervical MRI showed good recovery of spinal cord edema and perimedullary veins.