Direct carotid-cavernous fistula

Case contributed by Ryan Thibodeau


A patient presented with dizziness, headaches, nausea, and vomiting for several days after falling down 20 stairs resulting in head trauma with loss of consciousness. One day after admission to the hospital, she started to develop decreased visual acuity, eye pain, and photophobia.

Patient Data

Age: 55 years
Gender: Female

CT on bone window demonstrating fractures of the anteromedial wall of the right maxillary sinus, lateral wall of the right maxillary sinus, right zygomatic arch, and the right lateral orbital wall. There is layering blood within the right maxillary sinus. Layering acute blood is seen within the right maxillary sinus.

There is a left temporal lobe hemorrhagic contusion with surrounding cerebral edema. There is a layering subdural hematoma along left tentorial leaflet. There is minimal local mass effect with effacement of adjacent sulci.

Asymmetric enlargement and heterogeneous enhancement and enlargement of the left cavernous sinus, most easily seen on coronal imaging and resultant enlargement of the left superior ophthalmic vein with engorgement of the angular veins bilaterally.

On the frontal projection, a high-flow fistula between the cavernous segment of the left ICA and the cavernous sinus is noted. There is approximately a 2 mm carotid defect located at the short ascending segment of the cavernous ICA. Venous drainage toward the superior ophthalmic vein and toward the inferior petrosal sinuses was noted.

On the lateral projection, despite catheterization of the left ICA, there is opacification of the cavernous sinus.

Case Discussion

This is a case of a direct carotid-cavernous fistula (CCF) where there is an abnormal connection (fistula) between the cavernous segment of the internal carotid artery and the cavernous sinus. After days of progressively worsening visual acuity and eye pain, close examination noted exophthalmos of the left eye. A CT angiography of the brain was ordered and opacification of the cavernous sinus and left superior ophthalmic vein were noted, concerning for a CCF. The patient had a digital subtraction angiography (DSA) where the CCF was confirmed. A stent was placed over the fistula which seemingly corrected normal antegrade blood flow through the internal carotid artery.

Several weeks following the procedure, the patient began to experience recurrent symptoms. An emergent DSA was performed which demonstrated recurrence of the CCF. Transarterial coil embolization was performed at that time.

The patient followed up with neurosurgery 2 months after the embolization and has symptomatically doing well. Follow-up CTA was negative for recurrence of the CCF.


Chris McMahan

Allen Herr, MD

Joseph Giampa, DO

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