Carotid-cavernous fistula is an abnormal connection between the carotid artery and cavernous sinus. CT and MRI show proptosis, enlarged extraocular muscles, and dilated superior ophthalmic vein and cavernous sinus. Angiography demonstrates rapid filling of the cavernous sinus from the internal carotid artery. Treatment involves endovascular embolization or surgery to close the fistula.

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