Carotid Cavernous Fistula (CCF)

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Collateral venous drainage into the orbit and skull base was observed (Fig. A). After successful cannulation of the direct aperture between the right carotid artery and the cavernous sinus, balloon-assisted coil embolization of the posterolateral compartment was performed until the fistula was closed (Fig. B and C). She experienced immediate cessation of her pulsatile tinnitus with the early improvement of the right VI nerve palsy and near-complete recovery of her vision within 6 weeks.

Figure: (A) Right ICA Cavernous Fistula with Venous Shunting (B) Balloon Assisted Coil Embolization (C) Fistula Cured Post Embolization

Key Learning Points:

  1. Carotid-Cavernous Sinus Fistula (CCF) may occur because of traumatic or spontaneous communication in the walls of the intra-cavernous ICA or its branches directly to the cavernous sinus resulting in short-circuiting or shunting of high-pressure arterial blood into the venous system of the cavernous sinuses.
  2. Intra-cavernous aneurysms are often felt to predispose to a Direct CCF which have high rates of arterialized blood flow and can result in rapid progression of clinical symptoms including cranial nerve injury and vision loss.
  3. Early evaluation by a neurovascular specialist is recommended for patients presenting with new-onset or progressive pulsatile tinnitus, especially in patients with associated visual symptoms or new neurologic deficits.

Reference:
Endovascular Techniques for Treatment of Carotid-Cavernous Fistula. Gemmete J Ansari S, Gandhi D. Journal of Neuro-Ophthalmology. March 2009 – Volume 29 – Issue 1 – p 62-71.

CATEGORY: ENDOVASCULAR // CAROTID CAVERNOUS FISTULA (CCF)

Carotid Cavernous Fistula (CCF)

A 61-year-old woman who is otherwise healthy presented to her PCP with progressive right-sided pulsatile tinnitus for 4-6 weeks. Her PCP and ENT evaluated her extensively and prescribed multiple courses of steroids and subsequent unremarkable MRI and MRA imaging. She developed acute onset diplopia secondary to a new partial right VI nerve palsy several days prior to our evaluation. A cerebral angiogram confirmed the presence of a high flow direct fistula of the right internal carotid artery–right cavernous sinus.

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