High-Flow Indirect Carotid-Cavernous Fistula with Transarterial and Transvenous Endovascular Treatment

Case Report

Austin J Radiol. 2023; 10(3): 1218.

High-Flow Indirect Carotid-Cavernous Fistula with Transarterial and Transvenous Endovascular Treatment

Alexandre Mello Savoldi, MD*; Mayara Thays Beckhauser, MD, MSc; Thiago Vilela Calzada Machado, MD; Gelson Luiz Koppe

Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná – Curitiba/PR, Brazil

*Corresponding author: Alexandre Mello Savoldi Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná – Curitiba/PR, Brazil. Email: alesavoldi94@gmail.com

Received: June 19, 2023 Accepted: July 19, 2023 Published: July 26, 2023

Abstract

Male, 39 years old, with a progressive headache for seven months, progressive right exophthalmos, right chemosis and conjunctival edema, pulsatile tinnitus and carotid bruit in the right frontotemporal region. Cerebral magnetic nuclear angioresonance showed multiple anomalous vascular structures near the sphenoparietal sinus, pterygoid plexus, superior and inferior orbital fissures, all on the right, with swelling of the basilar plexus. A diagnostic cerebral and cervical arteriography was performed, which showed a high-output indirect Carotid-Cavernous Fistula (CCF), nourished mainly by multiple dysplastic dural branches originating from the mandibular and pterygopalatine segments of the internal maxillary artery and secondarily by the inferolateral trunk. There was hypertensive venous drainage anteriorly through the ecstatic superior and inferior ophthalmic veins, corresponding angular and facial veins, and posteriorly to both cavernous sinuses, basilar plexus, superior petrosal sinuses, and internal jugular veins (Type D, Barrow Classification). The patient underwent arterial embolization with hystoacril and lipiodol in branches of the right internal maxillary artery and venous embolization with platinum micro coils with occlusion of the fistula. He evolved well with the improvement of symptoms, being discharged from the hospital and scheduled for outpatient follow-up.

The CCFs are an abnormal shunt between arteries and veins within the cavernous sinus, mainly causing a change in the distribution of cerebro-orbital blood flow. The CCFs can be spontaneous or traumatic, with high or low flow. Due to the anatomical differences, Barrow’s classification categorizes CCF according to the angiographic pattern of arterial flow, as type A or direct (direct communication between the cavernous segment of the internal carotid artery and the cavernous sinus) and type B-D or indirect (indirect communication between branches of the internal and/or external carotid arteries and the cavernous sinus). Symptoms result from venous hypertension in the venous sinuses and reversal of flow to the veins. Due to the anatomical complexity of CCF, treatment is a challenge, and the goal is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus. Endovascular treatment is the first choice with occlusion of the fistulous area using materials such as a detachable balloon, coils, liquid embolic agents or covered stents. Type A fistulas are usually treated transarterial, and type B–D, by transarterial and/or transvenous embolization.

Keywords: Carotid-cavernous fistula; Cavernous sinus; Endovascular treatment

Introduction

Cavernous Carotid Fistulas (CCFs) represent abnormal arteriovenous communication between the cavernous sinus and the carotid arterial system (internal and external carotid arteries) [1-3]. They can be characterized by high or low flow, direct or indirect (dural), traumatic or spontaneous. The clinical manifestations can vary according to the type of FCC and the venous drainage pattern [1-4].

Barrow classification categorizes the CFF into direct (type A) and indirect (types B, C and D) types. Type A is a direct high-flow shunt between the internal carotid artery and the cavernous sinus. Type B is a dural shunt between meningeal branches of the internal carotid artery and the cavernous sinus. Type C is a dural shunt between meningeal branches of the external carotid artery and the cavernous sinus. Type D is a dural shunt between meningeal branches of the internal and external carotid arteries and the cavernous sinus [5].

Direct FCCs have a rapid flow. They are more common in young men, frequently caused by traumatic insult, by rupture of an internal carotid artery aneurysm within the cavernous sinus, associated with an underlying connective tissue disorder (Ehlers-Danlos syndrome type IV), or iatrogenic intervention [1-4].

Indirect FCCs usually have a low flow and are more common in middle-aged women, with 25% of these fistulas being spontaneous; other causes include hypertension, fibromuscular dysplasia, Ehlers-Danlos type IV, and dissection of the internal carotid artery [1-3].

Citation: Savoldi AM, Beckhauser MT, Machado TVC, Koppe GL. High-Flow Indirect Carotid-Cavernous Fistula with Transarterial and Transvenous Endovascular Treatment. Austin J Radiol. 2023; 10(3): 1218.