Imaging findings and outcomes in patients with carotid cavernous fistula at Inkosi Albert Luthuli Central Hospital in Durban

Background: Carotid cavernous fistulas (CCFs) are relatively uncommon and are difficult to diagnose clinically. Radiological imaging plays a significant role in making the diagnosis with recent advances improving the ability of radiologists to diagnose the condition. Despite these developments, digital subtracted angiography (DSA) remains the gold standard in diagnosing CCFs and simultaneously provides the opportunity for intervention. Objectives: To determine the imaging findings of patients presenting to Inkosi Albert Luthuli Central Hospital (IALCH) with a CCF and to assess the outcome of endovascular intervention. Method: We reviewed the electronic records and archived imaging data of consecutive patients diagnosed with CCF between January 2003 and May 2016 at IALCH, in particular, the imaging findings, intervention and subsequent outcomes. Results: Computed tomography (CT) was the most utilised imaging modality prior to patients undergoing DSA. A dilated superior ophthalmic vein (96%) was the most prevalent imaging finding on axial imaging. At DSA, all except two patients had high-flow fistulas. The fistulas predominantly drained anteriorly (69.44%) and a cavernous internal carotid artery aneurysm was identified in eight patients. Occlusion of the fistula was attained in all patients that were compliant with follow-up and underwent intervention (n= 36, 100%), but parent artery sacrifice was required in 10 cases (27.78%). Conclusion: A wide range of imaging modalities can be used in the workup of a CCF. CT is currently the most accessible modality in our setting, with limited access to magnetic resonance imaging. On axial imaging, a dilated superior ophthalmic vein is the commonest finding. Classification of a fistula according to flow dynamics and noting the presence of aneurysms or pseudoaneurysms was found to be more practical in comparison to the traditional Barrow's classification. Management outcomes at our institution compare well with available local and international data

Importancia del método clínico en el diagnóstico de la fístula carótido-cavernosa / Importance of the clinical method in the diagnosis of the carotid-cavernous fistula

Se describe el caso clínico de un paciente de 49 años de edad, que a causa de una crisis hipertensiva presentó una proptosis con enrojecimiento en el ojo derecho, por lo cual recibió diferentes diagnósticos y tratamientos. Debido a que el paciente no mejoraba y aparecían otras manifestaciones clínicas, fue remitido a las consultas de Glaucoma y Neuroftalmología del Centro Oftalmológico de Santiago de Cuba, donde se le realizaron estudios que condujeron al diagnóstico definitivo de fístula arteriovenosa cavernosa carotídea en el lado derecho, indirecta y de bajo flujo. Se indicó compresión manual externa de la carótida, con lo cual se logró la obliteración de la fístula y la mejoría del afectado

The case report of a 49 years patient that presented a proptosis with right eye reddening due to a hipertensive crisis is described, reason why he received different diagnosis and treatments. As the patient didn't improve and other clinical features appeared, he was referred to the Glaucoma and Neurophthalmology Service of the Ophthalmologic Center in Santiago de Cuba, where some studies were carried out which lead to the definitive diagnosis of indirect and of low flow carotid cavernous arteriovenous fistula in the right side. External manual compression of the carotid was indicated and the obliteration of the fistula and improvement of the affected patient was achieved

Advances in the endovascular treatment of direct carotid-cavernous fistulas / Avanços no tratamento endovascular de fístulas carotidocavernosas diretas

SUMMARY Carotid cavernous fistulas (CCFs) are abnormal connections between the carotid artery and the cavernous sinus. They are considered direct when there is a direct connection between the internal carotid artery and the cavernous sinus. These cases are generally traumatic. Direct CCFs are high-flow lesions, possibly related to intracranial bleeding, visual loss, corneal exposure or even fatal epistaxis. Treatment of such lesions is, thus, always recommended. The ideal treatment for direct CCF is to exclude the fistula from circulation, preserving the carotid flow. This can be attained using diverse endovascular techniques. The objective of the present article is to review the current techniques for treatment of direct CCFs, with special attention to the currently available endovascular treatment options.

RESUMO As fístulas carotidocavernosas (FCC) são comunicações anormais entre a artéria carótida e o seio cavernoso. Elas são consideradas diretas quando há uma comunicação direta entre a artéria carótida interna e o seio cavernoso. Nesses casos, são geralmente traumáticas. As FCC diretas são lesões de alto fluxo, podendo estar relacionadas a sangramento intracraniano, perda visual, exposição corneana ou até mesmo a epistaxe fatal. Seu tratamento é sempre indicado. O tratamento ideal da FCC direta é a exclusão da fístula da circulação, com preservação do fluxo carotídeo. Isso pode ser obtido por meio de técnicas endovasculares diversas. O objetivo do presente artigo é realizar uma revisão sobre as FCC diretas, com especial enfoque nas opções de tratamento endovascular disponíveis na atualidade.

Fístula carotídeo-cavernosa / Carotid-cavernous fistula

Fístulas carotídeo-cavernosas são raras. São classificadas nos tipos direto e indireto. Fístulas diretas têm uma comunicação anormal entre a artéria carótida interna e o seio cavernoso. Nas formas indiretas a conexão se faz entre os ramos meningeos da carótida interna e/ou externa e o mesmo seio. O propósito deste artigo é o de atualizar os conceitos anatômicos, clínicos, diagnósticos e terapêuticos desta situação.

Carotid cavernous fistulae are an uncommon disease. They are classified as direct or indirect. In direct fistulas there is an abnormal communication between the internal carotid artery and the cavernous sinus. Indirect forms have an abnormal bypass between the meningeal branches of the internal and/or external carotid arteries and the same sinus. The purpose of this article is to provide an overview of the anatomy of the envolved area and the clinical findings, diagnostic evaluation and treatment.

case report of cavernous sinus embolisation for CCF with an overview of treatment options

Carotid-cavernous fistulas [CCFs] are a subtype of intracranial arteriovenous fistulas with symptoms ranging from none to devastating intracranial hemorrhage. This article reviews the two main types of CCFs, the symptomatology, the different drainage patterns and the currently available treatment options. We follow that by a case report of a spontaneous CCF treated successfully by trans-arterial coil embolisation

Clinical spectrum of spontaneous carotid-cavernous fistula.

A carotid-cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system. A CCF is divided into two categories, direct and indirect. Direct fistulas usually account for 70 to 90% of all CCF. Spontaneous, low-flow fistulas are usually associated with atherosclerosis, hypertension and collagen vascular disease or may develop in females during peripartum period. The elderly age group, especially women are at increased risk. We report three cases of spontaneous CCF presenting with ocular manifestations and hypertension, without any collagen vascular disease. One case was a direct variety and the other two were of indirect variety.

Disecciones carotideas espontaneas complicadas: a proposito de dos casos tratados por via endovascular / Complicate spontaneous carotid dissectios: report of two cases managed endovascularly

Objective: to report 2 cases of spontaneous carotid dissection (SCD) that presented a pseudoaneurysm as a complication. Description: we report a case of a 47 year old patient with headache and Horner syndrome. The digital angiography (DA) showed a SCD. That was followed by a pseudoaneurysm. A 46 year old patient presented with a right amaurosis fugax and left hemiparesis. A SCD was diagnosed by magnetic resonance angiography. It presented with a pseudoaneurysm. Intervention: both pseudoaneurysm were treated with stents. Conclusion: DA is the method of choice for the diagnosis and evolutive dynamic control of SCD. Stents are useful pseudoaneurysm resolution

Tratamiento endovascular de las fistulas carotido-cavernosas / Endovascular treatment of the carotid-cavernous fistula

En los últimos 3 años fueron tratadas 23 fístulas carótido-cavernosas, en el Hospital Universitario San Vicente de Paúl (Universidad de Antioquia), por el grupo de terapia endovascular. La causa en el 65 por ciento de los casos fue el trauma cráneo encefálico (TCE) y en el 35 por ciento restante fueron heridas penetrantes. En 11 pacientes se sacrificó la arteria portadora de la fístula, pues en 9 de estos se encontraron lesiones asociadas (7 disecciones con pseudoaneurismas, 2 con estenosis carotídea severa) y en 2 existieron dificultades técnicas. En los 12 pacientes restantes se respetó la arteria portadora de la fístula. No hubo morbimortalidad y el éxito terapéutico fue del 96 por ciento en el seguimiento de 6 a 36 meses

Hemorragia digestiva superior por pseudoaneurisma de la arteria esplenica: tratamiento eficaz con embolización arterial / Upper gastrointestinal bleeding caused by pseudo aneurism of splenic artery: treatment efficacious with embolization artery

Se presenta el caso de un paciente joven con pancreatitis crónica cuya evolución se vio complicada con episodios intermitentes de hemorragia digestiva superior de origen oculto, por el lapso de un año antes de su diagnóstico. La angiografía abdominal demostró la existencia de un pseudoaneurisma de la arteria esplénica, producto de la digestión enzimática de sus paredes. Hubo ruptura de su cavidad hacia el conducto de Winsung lo que explicaba la ausencia de lesiones sangrantes identificables en las repetidas gastroscopias a las que el paciente fue sometido, aunque aparecían coágulos frescos en la segunda porción duodenal. La angiografía permitió, luego de dos sesiones de trabajo, la embolización completa de la cavidad de esta lesión utilizando varios espirales de tungsteno. La fuga distal de uno de estos espirales no tuvo consecuencias. Se hace énfasis en las posibilidades terapeúticas de la Radiología Intervencionista, en estos casos, gracias a la rápida evolución de los materiales disponibles para ello, constituyendo una alternativa válida al tratamiento quirúrgico standart