Carotid Cavernous Fistula (CCF)

The author would like to thank Drs Thanwa Sudsang and Tom Osborne for helping with labeling the vessels in these angiographic images.

AP and lateral views of the right carotid artery injection show simultaneous opacification of venous structures (superior/inferior ophthalmic veins, middle cerebral vein) and dilatation of the veins due to the presence of CCF in this patient who had recent head trauma.

Facts: CCF

• Rent in the wall of cavernous carotid artery with fistulous communication to the venous spaces of the cavernous sinus
• Either due to trauma (post-traumatic CCF) or ruptured cavernous carotid artery aneurysm
• Traumatic CCF typically seen in young adult male, post motor vehicle collision
• Non-traumatic CCF seen in elderly, female more common than male
• Clinical: venous hypertension (i.e., proptosis, chemosis, retinal hemorrhage, headache)
• Feared complication: venous hypertension of deep vein system and subsequent venous infarction (this can occur if flow from carotid into the cavernous sinus is diverted into deep venous system)

Urgent Treatment Required If:

• Worsening symptoms: increasing proptosis, diminishing visual acuity, increasing intraocular pressure, elevated intracranial pressure
• Extension of pseudoaneurysm or venous varix, or rupture into subarachnoid space

Treatment: endovascular occlusion of fistula with a detachable balloon device, while preserving flow in the carotid artery. Coil embolization is an alternative possible treatment.

Reference:

Morris P. Practical Neuroangiography, 2nd edition, 2007.