CAROTID CAVERNOUS FISTULA AN OVERVIEW

1. CAROTID –CAVERNOUS
FISTULA
Dr Arun Gupta
Director imaging
Deptt
Dr Rakhee Gupta
Dr R K Gandhi
Dr Vinayak Mittal
Dr Ritesh Mahajan

2. CAROTID CAVERNOUS
FISTULA
DEFINITION BEST DIAGNOSTIC CLUE
 Carotid – cavernous Proptosis .
fistula ( CCF ), Direct CCF,
Dilated superior
High velocity CCF .
ophthalmic vein and
 High flow fistula between
Cavernous sinus .
the cavernous ICA and
cavernous sinus .

3. CAROTID CAVERNOUS
FISTULA
CT FINDINGS MR FINDINGS
 Large cavernous sinus with
Proptosis signal voids ( t1w) .
Orbital edema  TI ( C) :
Enlarged extra ocular  Enlarged enhancing cavernous
sinus and SOV.
muscles  Adjacent or diffuse dural
enhancement .
SAH : secondary to reflux
MRA :
from the cortical veins Increased flow related signal in
( Rupture ) . the CS .
Increased signal void in CS : Due
Prominent SOV and to increased turbulence
Cavernous sinus Flow in SOV and /or trans-sellar
( may be bilateral) . collaterals .

4. CAROTID CAVERNOUS
FISTULA
USG findings Angiographic findings
 Very rapid filling of enlarged
Doppler shows reversal CS after ICA injection .
of the flow direction in  Common drainage pathways
SOV ( posterior to ( SOV & IOV ..Facial vein) .
 Other drainage pathways
anterior ) .  Superior and inferior petrosal
sinuses ..INTERNAL JUGULAR
VEIN
 Opposite CS via trans-sellar or
basilar plexus .
 Vein of Rosenthal ..vein of Galen .
Signs of danger : Filling of cortical
veins , pseudoaneurysm , CS
varices , thrombosis / obstruction
of venous drainage .

5. D/D
Enlarged Extra ocular
Enlarged SOV
muscles
CS thrombosis : No Grave’s and
fistula on angiography . inflammatory
Grave’s disease : Signs pseudotumor
of hyperthyroidism. Intra-muscular masses
Masses in orbital apex. ( Metastases) .

6. CAROTID CAVERNOUS
FISTULA
Pathology Etiology & types
 Skull base fracture commonest .
Blood from cavernous  Ruptured cavernous ICA aneurysm .
ICA to CS ..SOV and  Younger individuals (prone to trauma )
average age ( 37 years) . Gender : male .
petrosal sinuses.
 Individual with collagen vascular
Reflux from cerebral disorders
cortical veins occurs  Most tears involve the proximal
horizontal or vertical cavernous ICA .
when SOV/IOV and
 Type A : Direct communication
petrosal sinuses cannot between ICA and cavernous sinus
handle large blood  Type B-D : Indirect
volume …increased risk communications between the
of SAH . meningeal/dural branches of
ICA/ECA and cavernous sinus .

7. PROMINENT
SUPERIOR OPTHALMIC VEIN
T1W SEQUENCE T2W SEQUENCE

8. PROPTOSIS , PERIORBITAL EDEMA
ENLARGED EXTRA OCULAR MUSCLES

9. ENLARGED CAVERNOUS SINUS ( Rt )
WITH MULTIPLE FLOW VOIDS IN IT .

10. NORMAL
CAVERNOUS
SINUS AND
ICA
CAROTID
CAVERNOUS
FISTULA TYPES

11. CAROTID CAVERNOUS
FISTULA
PRESENTATION TREATMENT
 Symptoms develop either Spontaneous thrombosis
spontaneously or days / rare , progresses if
wks after trauma untreated .
 Bruit ( 50%) , pulsating
ICA / JUGULAR vein
exophthalmos , orbital
edema / erythema , compression ..only for
decrease vision, glaucoma , small CCF
headache . Severe rapid Embolization (coiling or
vision loss ,SAH , Focal
deficits ( CN 3-6). ( these balloon) : Trans-arterial
findings may be unilateral or transvenous .
/ bilateral) . Surgery / Gamma knife .

12. References
•F A T T A H I T T E T A L : T R A U M A T I C C A R O T I D - C A V E R N O U S
FISTULA ; PATHOPHYSIOLOGY AND TREATMENT . J
CRANIOFACSURG 14 :240-46,2003.
•C H U M A N H E T A L ; S P O N T A N E O U S D I R E C T C A R O T I D -
CAVERNOUS FISTULA IN EHLER-DANLOS SYNDROME
TYPE 4 : TWO CASE REPORTS AND A REVIEW OF THE
LITRETURE . J NEUROOPHTHALMOL 22:75-81,2002.
•D I A G N O S T I C I M A G I N G B R A I N O S B O R N