Carotid Cavernous Fistula (CCF)

Collateral venous drainage into the orbit and skull base was observed (Figure 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 (Figure B and C). He experienced immediate cessation of his pulsatile tinnitus with an early improvement of the right VI nerve palsy and near-complete recovery of his 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 intracavernous 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 has high rates of arterialized blood flow and can result in a 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.