Hemicranial Cough-Induced Headache as a First Symptom of a Carotid-Cavernous Fistula-Case Report.

Background and objectives: Spontaneous carotid-cavernous fistulas (CCFs) are rare, and they may be caused by an aneurysm rupture. Materials and Methods: A case of a man hospitalized for high-intensity hemicranial headache with sudden cough onset as part of an upper respiratory tract infection is presented. The pain was of a pulsating character, localized on the right, behind the eye, followed by nausea and vomiting. Neurological finding registered a wider rima oculi to the right and slight neck rigidity. Laboratory findings detected a mild leukocytosis with neutrophil predominance, while cytobiochemical findings of CSF and a computerized tomography (CT) scan of the endocranium were normal. Results: Magnetic resonance imaging (MRI) angiography indicated the presence of a carotid cavernous fistula with a pseudoaneurysm to the right. Digital subtraction angiography (DSA) was performed to confirm the existence of the fistula. The planned artificial embolization was not performed because a complete occlusion of the fistula occurred during angiographic examination. Patient was discharged without subjective complaints and with normal neurological findings. Conclusions: Hemicranial cough-induced headache may be the first sign of carotid cavernous fistula, which was resolved by a spontaneous thrombosis in preparation for artificial embolization.

Multidetector CT angiography in the diagnosis and classification of carotid-cavernous fistula.

AIM: To evaluate the performance of multidetector computed tomography angiography (MDCTA) in identifying and classifying carotid-cavernous fistulas (CCFs). MATERIALS AND METHODS: The neuro-interventional database was searched for patients with CCFs at four different institutions and for normal controls at one of the four institutions. Thirty-four patients were divided into the case group (direct type, n=8; indirect type, n=8) and the control group (n=18). Two readers retrospectively evaluated thin-section CTA images for the presence and laterality of four findings: (1) engorged ophthalmic vein, (2) engorged cavernous sinus, (3) similar enhancement of the cavernous sinus (CS) and internal carotid artery (ICA), and (4) greater enhancement of the CS than the transverse sinus (TS). Dehiscent ICA for the direct type was assessed only in the case group. Sensitivity, specificity, and inter-reader agreement were determined. Attenuation differences between the ICA and CS and between the CS and TS were compared across groups. RESULTS: The sensitivity/specificity for two engorgement and two enhancement findings were 81%/100%, 88%/94%, 100%/100%, and 88%/100%, respectively, for Reader 1, and 75%/100%, 75%/100%, 88%/100%, and 88%/100%, respectively, for Reader 2. Agreement between readers was excellent for all findings (κ>0.80). Dehiscent ICA identified the direct type with a sensitivity/specificity of 100%/75% for Reader 1 and 100%/88% for Reader 2 (κ=0.871). In the case group, the difference between ICA and CS attenuation values was significantly lower (180.1±76.6 versus 7.5±23.7; ⤳<0.001) and that between CS and TS were higher (-31.2±69 versus 102.6±59.3; ⤳<0.001). The area under the curve for the latter values was 0.95. CONCLUSION: The engorgement and enhancement categories in MDCTA may perform comparably in identifying CCFs and measurements of vessel attenuation differences may be of high diagnostic value. Dehiscent ICA can greatly aid in identifying the direct type.

Subfoveal choroidal thickness changes in carotid cavernous fistula following spontaneous resolution.

BACKGROUND: We report the enhanced depth imaging optical coherence tomography (EDI-OCT) characteristics and variations in a patient with subretinal fluid secondary to a carotid cavernous fistula. CASE PRESENTATION: A 59-year-old man presented with blurred vision in his right eye. Venous congestion of the epiescleral and retinal vessels were observed. EDI-OCT disclosed macular subretinal fluid with an increase of choroidal thickness up to 341 µm. Brain and orbital computerized tomography showed an enlarged right superior ophthalmic vein. Orbital magnetic resonance imaging and angiography disclosed a decrease in blood flow, an indirect sign of carotid cavernous fistula. After a 3 months follow-up, spontaneous closure of the fistula occurred. Both the dilation of the conjunctiva and retinal veins improved. EDI-OCT showed resolution of the subfoveal fluid and a reduction of the subfoveal choroidal thickness to 271 µm after a 3 months follow-up and 168 µm after a 8 months follow-up. CONCLUSION: Serous retinal detachment has been described as a rare complication of carotid cavernous fistula. In our patient, EDI-OCT examinations revealed a thicker choroidal thickness when subretinal fluid was present as compared to that observed in the contralateral eye or after subretinal fluid resolution.

Endovascular Modalities for the Treatment of Cavernous Sinus Arteriovenous Fistulas: A Single-Center Experience.

BACKGROUND: Cavernous sinus (CS) fistulas are classified into traumatic and spontaneous. Traumatic carotid-cavernous fistulas (CCFs) are usually direct internal carotid artery (ICA) high-flow fistulas; whereas spontaneous CCFs are usually dural, low-flow fistulas and generally possess less severe symptoms than direct carotid-cavernous fistulas. METHODS: This study involved 34 patients who were classified into 2 groups: Group A included 26 patients with direct carotid-cavernous fistula; and Group B included 8 patients with indirect dural cavernous fistula. All patients had ocular manifestations. One patient had subarachnoid hemorrhage. Coils were used alone in 19 cases of direct fistula and in 1 case of dural fistulas. Coils and Onyx (Covidien, Mansfield, MA, USA) were used in 7 cases of direct fistula and in 2 cases of dural fistulas. Onyx alone was used to treat 5 cases with dural fistulas but none of the cases with direct fistulas. Covered stents and coils were used in 2 cases of direct fistulas. RESULTS: All patients in both groups showed full recovery of their clinical signs and symptoms. Only 1 procedure-related complication was observed (3%) in which a patient had an embolic event and trigeminal dysesthesia as a result of Onyx reflux through external carotid artery-ICA anastomosis. CONCLUSION: Coils are superior solid embolic agents used for the treatment of direct high-flow fistulas, while Onyx is more valuable in dural low-flow CCF. Onyx shortens the procedure time and decreases procedure cost. Onyx injection inside the CS proper through the transarterial or transvenous route may be safer than Onyx injected inside dural arteries supplying the CS. However, more cases are needed to determine this.

Imaging anatomy and pathology of extraocular muscles in adults.

The extraocular muscles (EOM) are involved in a variety of disease processes with characteristic findings on imaging. EOM anatomy is described, followed by a review of adult EOM pathology. The imaging characteristics are explained with examples. The pattern of EOM disease on imaging, in corroboration with clinical findings, can often lead the radiologist towards a specific diagnosis.

Alteration of choroidal thickness in a case of carotid cavernous fistula: a case report and a review of the literature.

BACKGROUND: To measure the alterations of the choroidal thickness in Carotid cavernous fistula (CCF) using enhanced depth imaging optical coherence tomography (EDI-OCT). CASE PRESENTATION: A 64-year-old woman was referred to us for redness, exophthalmos and visual disturbance in her right eye. She was diagnosed with CCF by magnetic resonance imaging (MRI) and magnetic resonance angiography.Observations; Embolization resulted in improvement of ocular symptoms, and there was a reduction of the subfoveal choroidal thickness in the right eye from 351 µm preoperatively to 142 µm postoperatively in EDI-OCT. CONCLUSION: EDI-OCT demonstrated that the choroidal thickness increases occurred due to congestion in a CCF case.

Traumatic carotid-cavernous fistula at the anterior ascending segment of the internal carotid artery in a pediatric patient.

INTRODUCTION: Traumatic carotid-cavernous fistula (CCF) in children is a rare condition. Early diagnosis and treatment is still a challenge, and it is associated with good neurological recovery. CASE SUMMARY: We present a rare case of a 10-year-old boy with mild head trauma, who developed a CCF at the anterior segment of the ascending internal carotid artery. The patient was treated with endovascular coil embolization and evolved with a favorable outcome. DISCUSSION: Most of reports in the literature address the traumatic CCF in adult patients, in which early treatment may prevent poor recovery or fatal outcomes. The diagnosis and management of this condition are discussed based on a literature review. CONCLUSION: It is important to keep a high degree of suspicion for CCF, especially in traumatic head injury associated with skull base fracture, since the early diagnosis and treatment may prevent potentially permanent neurological deficits.

[Neuro-ophthalmology and interventional neuro-radiology--co-treatment for carotid cavernous sinus fistula].

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous communications in the cavernous sinus. In many cases of CCF's the primary signs are ocular manifestations, which include: pulsatile proptosis, orbital bruit, chemosis and conjunctival injection, elevated intraocular pressure, venous stasis retinopathy, and cranial nerve pareses. Patients in whom the fistula causes arterial drainage into the cerebral veins and sinuses are at risk for intracranial hemorrhage. The most common treatment for CCF's is endovascular occlusion of the lesion. The goal of this procedure is to occlude the fistula but preserve the patency of the internal carotid artery. The CCF itself, as well as its treatment, can be sight- and even life-threatening. We describe 3 case reports of patients with CCF, in order to demonstrate the cooperation between the neuro-opthalmologist and the invasive neuro-radiologist, in the follow-up of the patient and in the treatment timing decision.

Involvement of methicillin-susceptible Staphylococcus aureus related to sequence type 25 and harboring pvl genes in a case of carotid cavernous fistula after community-associated sepsis.

Staphylococcus aureus encoding Panton-Valentine leukocidin (PVL) genes has become the cause of life-threatening infections. We describe a case of carotid cavernous fistula after bacteremia in a 12-year-old male, caused by a methicillin-susceptible S. aureus isolate carrying the pvl, fnbA, and ebpS genes and related to sequence type 25 (ST25). The patient's condition was complicated by pleural empyema and osteomyelitis in the right femur. The patient was discharged in good clinical condition after 160 days of hospitalization.

Stereotactic radiosurgery in the treatment of a dural carotid-cavernous fistula.

Because of the success of stereotactic radiosurgery (SRS) in the treatment of cerebral arteriovenous malformations (AVMs), SRS is being applied to the treatment of carotid-cavernous dural arteriovenous fistulas (CCDAVFs) when these lesions are not accessible endovascularly. We report a patient with a CCDAVF that could not be accessed endovascularly on 2 attempts, whose fistula was successfully closed with SRS, a less invasive modality than endovascular embolization. Further experience with SRS in this role will be necessary to determine its utility.

Direct puncture of a prematurely detached balloon in the supraclinoid ICA via the optic canal during embolisation of a traumatic carotid-cavernous fistula.

We report a patient with traumatic carotid-cavernous fistula associated with an isolated internal carotid artery in whom, after trans-arterial balloon embolisation, premature balloon detachment occurred with balloon migration to the supraclinoid carotid artery, leading to total occlusion of the blood flow. The carotid flow was eventually restored by direct puncture of the detached balloon via the optic canal and by deploying a coronary stent to fix the balloon in the vascular wall. The fistula was eventually occluded by using detachable coils. He was discharged with a mild hemiparesis and decreased acuity in the left eye.

[Carotid-cavernous fistulas: Clinical features, management and differential diagnosis]. / Fistules carotidocaverneuses : présentation clinique, prise en charge et diagnostics différentiels.

Carotid-cavernous fistulas are abnormal communications between the carotid system and the cavernous sinus. Depending on their direct or indirect nature, they have different clinical manifestations and management. Are discussed in this paper: first the anatomy of the cavernous sinus, then clinical signs, diagnosis, management and differential diagnosis of carotid-cavernous fistulas.

Direct-puncture approach to the extraconal portion of the superior ophthalmic vein for carotid cavernous fistulae.

INTRODUCTION: The transvenous approach via the superior ophthalmic vein (SOV) is an available approach for carotid cavernous fistula (CCF), especially in the event that there is no other suitable approach route to the fistula. Surgical exposure of the peripheral roots of the SOV is commonly used; however, often, the SOV is often not accessible because of anatomical problems and/or complications. In this paper, we present and discuss our original direct-puncture approach to the extraconal portion of the SOV. METHODS: An attempt on three patients with traumatic CCF failed with the transarterial approach and the conventional venous approach via the inferior petrosal sinus; therefore, the patients were treated with the direct-puncture approach to the extraconal portion of the SOV using two-dimensional digital subtraction angiography with local anesthesia. RESULTS: All cases that had tortuous and partially stenotic division of the SOV were treated successfully with this approach and without complications. CONCLUSION: This approach will become an alternate approach, especially when the peripheral roots of the SOV are focally narrowed and tortuous, making it impossible to insert a catheter.

Transarterial coil embolization of a carotid-cavernous fistula which occurred during stent angioplasty.

Intracranial endovascular procedures are less invasive and relatively safe; however, these procedures do carry a risk of complications, such as thromboembolization, arterial injury, and vessel occlusion. We present a case of carotid-cavernous fistula development secondary to injury of the cavernous segment of the internal carotid artery (ICA) during stent angioplasty and its treatment by transarterial coil embolization. Probable causes of this complication and its treatment method are discussed. To the best of our knowledge, this is the first report of such a case.

Cavernous sinus fistula treated through the transvenous approach: report of four cases.

PURPOSE: To describe transvenous embolization in four patients with indirect dural carotid cavernous fistulas (CCFs) via the inferior petrosal sinus (IPS) or superior ophthalmic vein (SOV), and their clinical outcomes. METHODS: The CCF approach was performed after retrograde venous catheterization from the femoral vein to the cavernous sinus via the IPS (n=1) or SOV (n=3). SOV catheterization was possible without surgical intervention. All patients presented initially with typical clinical signs of CCF. Patients treated via the SOV presented with thrombosis of the IPS. RESULTS: Catheterization and embolization were successful in all patients, with complete angiographic occlusion of the fistula. No early or late complications occurred. All patients presented with favorable clinical outcomes and complete recovery of ocular symptoms. CONCLUSION: Retrograde transvenous embolization of CCF via the IPS, or SOV if the IPS is thrombosed, is a safe procedure with a good clinical outcome.

XCalibur aneurysm occlusion device for the treatment of direct carotid cavernous fistula: expansion of armamentarium.

We report the first case of a post-traumatic direct carotid cavernous fistula (CCF) treated with the XCalibur aneurysm occlusion device, which is a balloon mounted stent with flow diversion effect. Two devices were deployed across the fistula in an overlapping manner, resulting in complete occlusion of the fistula. Flow diversion with this device can provide a safe and alternative treatment option in direct CCF.

Carotid cavernous fistula in CNS choriocarcinoma.

Carotid artery-cavernous sinus fistulas (CCFs) are infrequently reported in the pediatric population, and are rarely reported in conjunction with CNS neoplasms. The authors present a 7-year-old girl with CNS choriocarcinoma who acutely developed left eye proptosis and conjunctival injection. Computed tomography angiography revealed a CCF, which was endovascularly embolized with detachable coils. There may be a direct cause-and-effect relationship between choriocarcinoma and development of CCFs.