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Traumatic Carotid Cavernous Fistula


KEY FACTS

Terminology

  • Direct carotid cavernous fistula (CCF), high-flow CCF

  • Single-hole tear/transection of cavernous internal carotid artery (ICA) with arteriovenous shunt into cavernous sinus (CS)

Imaging

  • General features

    • Proptosis, dilated superior ophthalmic vein (SOV) and CS, extraocular muscle enlargement

    • Skull base fracture involving sphenoid bone/carotid canal ↑ likelihood of ICA injury

  • MRA: ↑ flow-related signal in CS and SOV

  • CT/CTA may be suggestive; should proceed to DSA to confirm and treat

  • DSA is definitive

    • Early filling of CS + outflow pathways including retrograde filling of SOV, angular + facial veins

    • Reduced or absent antegrade flow in ICA beyond fistula, depending on size of ICA tear

Top Differential Diagnoses

  • Indirect CCF

    • Low-flow CCF

    • CS dural arteriovenous fistula

    • Often older patient without history of trauma

Clinical Issues

  • Bruit, pulsating exophthalmos, orbital edema/erythema, ↓ vision, glaucoma, headache

  • Hemispheric ischemia if ↓ flow in ICA beyond CCF

  • Focal deficits → cranial nerves 3-6 (ptosis)

  • Endovascular treatment options include

    • Transarterial-transfistula balloon embolization

    • Transvenous embolization

    • Pipeline/covered stent placement

    • ICA sacrifice

Coronal graphic depicts a carotid cavernous fistula (CCF). The right cavernous sinus
is enlarged. Note numerous dilated arterial and venous channels
within the laterally bulging cavernous sinus.

Clinical photograph depicts findings in posttraumatic right carotid cavernous fistula. Pulsatile exophthalmos
with 3, 4, and 6 nerve palsies including ptosis
was present.

CECT scan in a patient with posttraumatic pulsatile exophthalmos shows that the right cavernous sinus
is enlarged. The ipsilateral superior ophthalmic vein
is more than 4x the size of the left superior ophthalmic vein
.

DSA in the same case shows opacification of the cavernous sinus
in the arterial phase. Also outlined are many of the venous outflow pathways of the cavernous sinus, including the superior ophthalmic vein
, superior and inferior petrosal sinuses
, and pterygoid and pharyngeal venous plexi
.

TERMINOLOGY

Abbreviations

  • Carotid cavernous fistula (CCF)

Synonyms

  • Direct CCF, high-flow CCF

Definitions

  • Single-hole tear/transection of cavernous internal carotid artery (ICA) with arteriovenous shunt into cavernous sinus (CS)

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