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Medicine (Baltimore) 2021 Jun;100(24):e26383

Department of Radiology.

Rationale: Sphenoid sinus pseudoaneurysm arising from the cavernous segment of the internal carotid artery (ICA) caused by traumatic vessel injury is rare, and rarer is a concomitant carotid-cavernous fistula (CCF). In particular, delayed subarachnoid hemorrhage (SAH) due to pseudoaneurysm rupture has not been reported to-date in literature. Here, we report a case of sphenoid sinus pseudoaneurysm with CCF presenting with delayed SAH. Read More

BMJ Case Rep 2021 May 27;14(5). Epub 2021 May 27.

Child Sight Institute, Jasti V Ramanamma Children's Eye Care Centre, LV Prasad Eye Institute, Hyderabad, Telangana, India.

A 36-year-old man presented with proptosis and external ophthalmoplegia of the left globe following road traffic injury. Cerebral angiogram revealed moderate flow direct carotid cavernous fistula on left side for which coil embolisation was done repeatedly. Subsequently, the patient developed decreased vision in left eye and developed features of left-sided ocular ischaemic syndrome. Read More

Clin Case Rep 2021 May 4;9(5):e04117. Epub 2021 May 4.

Neurosurgery Department Sarawak General Hospital Kuching Malaysia.

Caroticocavernous fistulae can occur following transsphenoidal surgery even without evidence of carotid artery injury. A role of vascularized flap reconstruction may be contributory. Read More

Radiol Case Rep 2021 Jul 7;16(7):1806-1809. Epub 2021 May 7.

Department of Neuroradiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Road, Jiao-Su Village, Yan-Chao District, Kaohsiung, Taiwan.

We present a transvenous embolization technique for a direct carotid-cavernous fistula through the pterygoid plexus to the cavernous sinus which only 2 cases have been previously reported in the English literature. This method is appropriate when transarterial techniques or other attempts at transvenous access have failed due to vessel tortuosity, hypoplasia, stenosis, or occlusion. A middle-aged female patient presented with progressive left exophthalmos with conjunctiva chemosis and bruit after sustaining a falling injury. Read More

NMC Case Rep J 2021 Apr 2;8(1):13-19. Epub 2021 Apr 2.

Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan.

Herein, we describe a case of traumatic direct carotid cavernous fistula (DCCF) treated with target coil embolization using the combined transarterial and transvenous balloon-assisted technique. The patient was a 59-year-old woman who had been involved in a vehicular accident. She was admitted to the hospital due to chemosis and exophthalmos. Read More

Turk Neurosurg 2020 Oct 19. Epub 2020 Oct 19.

Suleyman Demirel Universitesi.

An 11-year-old girl presented with bilateral traumatic caroticocavernous fistula (CCF) associated with corkscrew eyelid vessels, which were considered indicators of severe congestive disease in this case. Direct CCFs are commonly associated with a history of head trauma, high-flow, prominent eye findings, and requirement for an early treatment. Indirect CCFs on the other hand are usually spontaneous, and associated with low flow, subtle findings and a benign course. Read More

Interv Neuroradiol 2021 May 10:15910199211014701. Epub 2021 May 10.

Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece.

Introduction: Carotid cavernous fistulas (CCFs) are rare, usually follow head trauma or aneurysmal rupture. Recent treatment options include endovascular techniques such as flow diversion devices (FDDs).

Objective: To present our case treated with FDD application with transarterial cavernous-sinus coiling and present a systematic review on the use and effectiveness of FDDs in CCF treatment. Read More

Cureus 2021 Apr 2;13(4):e14261. Epub 2021 Apr 2.

Department of Ophthalmology, Division of Oculofacial Plastic & Orbital Surgery, Gavin Herbert Eye Institute, University of California, Irvine, Irvine, USA.

A 29-year-old man with a medical and social history notable for smoking presented with progressive orbital congestion, conjunctival injection, and extraocular muscle enlargement consistent with thyroid eye disease (TED). On ophthalmologic examination, tortuous episcleral vessels and blood in Schlemm's canal on gonioscopy clued an alternative diagnosis. Cavernous sinus enhancement on computed tomography also suggested a retro-orbital process. Read More

J Surg Case Rep 2021 Apr 22;2021(4):rjab140. Epub 2021 Apr 22.

Department of Ophthalmology, Loma Linda University School of Medicine, Loma Linda, CA, USA.

Bilateral carotid-cavernous fistula (CCF) is a rare disease process, which portends poor visual outcome with delayed diagnosis and treatment. An 82-year-old woman presented with sudden onset of proptosis and decreased vision. A complete ophthalmologic examination along with magnetic resonance (MR) imaging of the brain and orbits, and MR angiography and venography of the brain confirmed the diagnosis of bilateral CCF. Read More

J Binocul Vis Ocul Motil 2021 Apr-Jun;71(2):50-54. Epub 2021 Apr 15.

Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina.

: To describe a patient who presented with right unilateral white-eyed posteriorly-draining carotid-cavernous fistulas (CCF) causing an isolated, acute-onset trochlear nerve palsy with atypical progression to a contralateral left red-eyed anteriorly-draining CCF associated with orbital congestion.: A 74-year-old female presented with an acute onset incomitant right hypertropia consistent with the clinical diagnosis of a superior oblique palsy. Initial workup including MRI was normal. Read More

Oral Maxillofac Surg 2021 Apr 5. Epub 2021 Apr 5.

Unit of Interventional Neuroradiology, Careggi Hospital, Largo Piero Palagi 1, 50139, Florence, Italy.

Purpose: Carotid cavernous fistulas (CCFs) are abnormal connections between the cavernous sinus (CS) and carotid arteries. In direct CCFs, a transarterial route is often the preferred vascular access; in case of indirect CCFs, the complex anatomy of the feeder vessels and their extra-intracranial anastomosis makes the transarterial embolization challenging and often ineffective. The aim of this study was to review our experience with the transorbital approach to treat patients affected by CCF who have already experienced an endovascular failure procedure, in order to assess this salvage technique feasibility, by analyzing possible risks and complications. Read More

J Clin Neurosci 2021 Apr 11;86:230-234. Epub 2021 Feb 11.

Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran. Electronic address:

Background: Direct carotid cavernous fistula (CCF) occurs between the internal carotid artery (ICA) and the cavernous sinus. Carotid cavernous fistulas (CCFs) frequently present with chemosis, pulsatile proptosis, ocular bruit, vision loss, and occasionally intracerebral hemorrhage or seizure. In this article, we share our experience in endovascular treatment of six patients having this pathology with intracranial flow diverting stents with review of literatures. Read More

Clin Neurol Neurosurg 2021 May 20;204:106601. Epub 2021 Mar 20.

Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA.

Background: Carotid Cavernous Fistulas (CCFs) are the result of an abnormal communication between the carotid artery and its branches and the venous system of the cavernous sinus. The mainstay of therapy for CCFs consists of transarterial or transvenous embolization, while other treatment options such as open surgery or radiosurgery are still utilized as second-line or adjuvant therapeutic options.

Objective: Our aim was to systematically review and summarize available data regarding short- and long-term outcomes of all available treatment modalities for CCFs. Read More

Neuroradiology 2021 Jul 23;63(7):1149-1152. Epub 2021 Mar 23.

Department of Neuroradiology, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Aarau, Switzerland.

Carotid-cavernous sinus fistulas (CCFs) are abnormal communications between the internal carotid artery (ICA) and the cavernous sinus (CS). Direct CCFs are associated with trauma or are iatrogenic complications of neuroendovascular procedures. Meanwhile, mechanical endovascular thrombectomy (MT) in acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO) has been established as a common treatment approach. Read More

BMJ Case Rep 2021 Mar 22;14(3). Epub 2021 Mar 22.

Department of Neurological Surgery, University Hospitals, Cleveland, Ohio, USA.

Carotid-cavernous fistulas (CCFs) are abnormal connections between arteries and the cavernous sinuses. Traditionally, the Barrow Classification system has been used to characterise these fistulas based on their arterial supply from the internal carotid artery (ICA), external carotid artery (ECA) or both. We present a unique case of a patient with a complex CCF with arterial feeders from dural branches of the ECA, ICA and vertebral artery (VA), which, to our knowledge, has not been reported in the literature. Read More

J Cerebrovasc Endovasc Neurosurg 2021 Mar 17;23(1):54-59. Epub 2021 Mar 17.

Department of Interventional Neuroradiology, Universidade Federal de São Paulo, São Paulo, SP, Brazil.

This is a case demonstrating a combined traumatic lesion of the internal carotid artery (dissection and a carotid cavernous fistula [CCF]) in a patient who was beaten during a robbery and, while trying to escape, was hit by a vehicle. Endovascular approach for the treatment was chosen using the retrograde access from the vertebral artery to the cavernous sinus by posterior communicating (Pcom) artery due to the occlusion of the ipsilateral internal carotid. Because the artery access by the internal carotid was impossible, retrograde approach by vertebral artery and Pcom artery was done to treat the direct CCF. Read More

Vascular 2021 Feb 17:1708538121990120. Epub 2021 Feb 17.

Department of Vascular Surgery, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Ji'nan, China.

Objectives: This study was aimed to evaluate the safety and efficacy of endovascular treatment of extracranial carotid artery aneurysms (ECAAs) using self-expandable covered stent grafts.

Methods: All patients with ECAA at a single institution were reviewed from February 2014 to February 2020. Eight consecutive patients (three men, mean age 64. Read More

World Neurosurg 2021 May 9;149:e369-e377. Epub 2021 Feb 9.

Department of Neurosurgery, University of Arizona, Tucson, Arizona, USA. Electronic address:

Background: Carotid cavernous fistulas (CCFs) are pathologic connections between the carotid arteries and the cavernous sinus and have been classically treated with endovascular coil embolization, although flow diverters have been used for treatment successfully multiple times. The aim of this study is to systematically review the literature for efficacy of flow diverters in treating CCFs.

Methods: A systematic review was conducted using the PRISMA guidelines. Read More

Cureus 2020 Dec 26;12(12):e12297. Epub 2020 Dec 26.

Neurological Surgery, Advocate Christ Medical Center, Oak Lawn, USA.

Brain arteriovenous malformations (AVM) commonly present for medical attention after a patient experiences a rupture that results in a focal neurologic deficit, an epileptic event, or is found incidentally on cranial imaging performed for an unrelated reason. In contrast, carotid-cavernous fistulas (CCF) can develop high-flow arteriovenous shunting with symptoms attributable to venous hypertension. We discuss a unique case of a 54-year-old female presenting with signs and symptoms suggestive of a CCF but was found to have a perisylvian AVM with an enlarged draining vein draining into the cavernous sinus. Read More

Case Rep Anesthesiol 2021 5;2021:2342347. Epub 2021 Jan 5.

Penn State Milton S. Hershey Medical Center, Department of Anesthesiology & Perioperative Medicine, Hershey, PA, USA.

Carotid-cavernous fistulas (CCFs) are vascular shunts that allow blood to flow from the carotid artery or its branches into the cavernous sinus. Endovascular embolization is the treatment modality of choice. The trigeminocardiac reflex (TCR) is a vagally mediated reflex that can lead to hemodynamic instability. Read More

Ann Emerg Med 2021 02;77(2):179-220

Department of Emergency Medicine, Cook County Health, Chicago, IL.

Oper Neurosurg (Hagerstown) 2021 02;20(3):E251

Neurosurgical service, Beth Israel Medical Center, Harvard Medical School, Boston, Massachusetts.

Ophthalmologe 2021 Jan 18. Epub 2021 Jan 18.

Universitätsaugenklinik Erlangen, FAU Erlangen-Nürnberg, Erlangen, Deutschland.

Background: Symptoms and clinical findings in patients with carotid-cavernous fistulas are specific. Nevertheless, they can be very mildly expressed. This study aims to point out the potential diagnostic value of ultrasound of the orbit. Read More

BMJ Case Rep 2020 Dec 21;13(12). Epub 2020 Dec 21.

Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Post-traumatic direct carotid-cavernous fistulas may develop in patients with a closed head injury. The classical presentation is the Dandy's triad-chemosis, pulsatile proptosis and orbital bruit. Associated findings may include orbital pain, dilated episcleral corkscrew vessels, vision deficit and cranial nerve palsies. Read More

BMJ Case Rep 2020 Dec 23;13(12). Epub 2020 Dec 23.

Interventional Radiology, University of Florida College of Medicine, Jacksonville, Florida, USA.

Endovascular thrombectomy in acute ischaemic stroke commonly uses aspiration catheters, either alone or in combination with stent retrievers. The Penumbra Aspiration System (Penumbra, Alameda, California, USA) was first approved by the US Food and Drug Administration in 2007, with low reported device-related complications. We present a case of a previously unreported complication related to malfunction of a Penumbra aspiration catheter during stroke thrombectomy resulting in a carotid-cavernous fistula. Read More

World Neurosurg 2021 Apr 5;148:e121-e129. Epub 2021 Jan 5.

Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany.

Objective: The NeVa M1 thrombectomy device is a novel hybrid-cell stent retriever with multifunctional zones for optimized retrieval of resistant clots located in the M1 segment of the middle cerebral artery. The objective was to evaluate the safety and efficacy of the NeVa in a "real-life" setting.

Methods: Twenty-nine consecutive patients (median age: 77 years) treated with the NeVa M1 for acute ischemic stroke of the M1 segement were retrospectively reviewed. Read More

J Clin Neurosci 2021 Feb 24;84:106-110. Epub 2020 Dec 24.

Department of Neurosurgery, Fukui Prefectural Hospital, Fukui, 2 Chome-8-1 Yotsui, Fukui, 910-8526, Japan. Electronic address:

Dural carotid-cavernous fistulas (DCCF) are located in the cavernous sinus wall involving the arterial feeders from the external and internal carotid arteries. The venous route usually passes through the internal jugular vein and inferior petrosal sinus (IPS) up to the pathologic shunts of the cavernous sinus. In cases of a thrombosed IPS, catheterization is not always possible because of the obstruction. Read More

Porto Biomed J 2020 Nov-Dec;5(6):e097. Epub 2020 Nov 24.

Neurology Department, Centro Hospitalar Universitário de São João, E.P.E; Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, Porto University (FMUP).

Radiol Case Rep 2021 Jan 16;16(1):185-191. Epub 2020 Nov 16.

Radiology Center, Bach Mai Hospital, Ha Noi, Vietnam.

Direct anterior cerebral artery-cavernous sinus fistula is an extremely rare complication of head trauma. We describe a male patient (age 49 years) with a history of head trauma 15 years ago who was hospitalised for a bulging red eye and tinnitus. Digital subtraction angiography showed a direct anterior cerebral artery (fork junction A1 - prior passage)-cavernous sinus fistula. Read More

JAMA Ophthalmol 2021 01;139(1):119-120

Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, United Kingdom.