Carotid-cavernous fistula CCf

Question 1

CCF type

Barrow classification of CCFs

Answer 1

Type A direct ( MCC) ⬆️ high flow between ICA n cavernous ;
Type A1 direct CCF / A2 direct CCF + aneurysm
Traumatic , iatrogenic rhizotomy , spontaneous from cavernous ICA anurysum rupture

Type B indirect low flow from meningeal A ;; ICA
Type C MMA w/ ECA
Type D MMA w/ ICA + ECA ➡️ MCC low flow

Question 2

Sx presentation direct progressive vs indirect gradual

Answer 2

🔺🔺 common direct ➡️ chemosis, pulsatile proptosis, ocular bruit

⬇️ 👁️ ⏩️ hypoxia retina ➡️ ⬇️ arterial pressure ⬆️ venous pressure and IOP
CN6 palsy

Question 3

Proptosis best evaluate by

Answer 3

T2 coronal will 🔺 recuts m vs superior opthA v

Question 4

Imaging

Answer 4

CT , MRI ➡️ proptosis, engorged intraocular vessels including the superior ophthalmic vein
⭐️ Angi➡️ shunt I’m ICA and cavernous ;
1- Rapid opacification of petrosal sinus and/or ophthalmic vein may be seen.

Question 5

Huber maneuver

Answer 5

lateral view, inject VA and manually compress affected carotid. Helps identify upper extent of fistula, multiple fistulous openings, and complete transection of ICA

Question 6

Mehringer-Hieshima maneuver

Answer 6

inject contrast at a rate of 2–3 ml/s into affected carotid while compressing the carotid in the neck (below the catheter tip) to control flow to help demonstrate the fistula

Question 7

Low flow or indirect CCF associated

Answer 7

spontaneous thrombosis50%

Question 8

Indication for TX

Answer 8

1. proptosis
2. visual loss
3. cranial nerve VI palsy
4. intractable bruit
5. severely ⬆️ IOP intraocular pressure
6. increased filling of cortical veins on angiography

Question 9

TX

Answer 9

Low flow , spontaneous thrmbosis , f/ vision 👀 VA and IOP < 25
If sx progressive ⬇️⬇️👀 urgent 🚨 TX ( embolization)
Compression occlude CCF about 30% ➡️ use CI hand 🖐️

Question 10

Target 🎯 fromTX

Answer 10

Preserve 👀

Question 11

Tx choices

Answer 11

Direct coil or clip
Indirect coli

Question 12

Route for embolization

Answer 12

1-transarterial through internal carotid.if fail ICA sacrifice ( occlusion test is indicate befor )
2- transarterial through external carotid⏩️ use dural fistula
3- transvenous; IJV ⏩️ petrous Al ⏩️ cavernous
⬇️ success rate vs < trans-arterial

Question 13

Complication

Answer 13

Injury to the fragile vein due to ballon catheter
High direct CCF

Question 14

Min trunk involve CCF

Answer 14

meningo-hypophyseal trunk (most constant) and the inferolateral trunk.

Question 15

Iatrogenic cause of CCF

Answer 15

Iatrogenic may be due to craniotomy, carotid endarterectomy, transsphenoidal/sinus surgery, endovascular procedures,

Question 16

Common population

Answer 16

Traumatic CCF young
Indirect CCF / Spontnouse encounters 6 and 7 decades and female

Question 17

engorged superior ophthalmic vein sign ( > 4 mm ) DDX

Answer 17

orbital pseudotumor, cavernous meningioma and Grave’s ophthalmopathy

Question 18

If parent artery is damage

Answer 18

concern exists regarding catheterization of a disrupted vesse➡️ surgical option is best

Question 19

mainstay of treatment of direct CCFs.

Answer 19

Detachable coils ➡️ advanced ability to be retrieved in the event of inadequate placement.

Question 20

TVE Transvenous endovascular

Answer 20

Barrow type B CCFs

because of the risk of reflux of embolizate into the ICA.

Question 21

Radiosurgery CCF effective in

Answer 21

Low-flow indirect CCFs.

Question 22

High improv,ent in visual sx chemosis and proptosis

Answer 22

When combined radiosurgery and embolization strategy,