Carotid-cavernous fistula CCf Flashcards
CCF type
Barrow classification of CCFs
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
Sx presentation direct progressive vs indirect gradual
🔺🔺 common direct ➡️ chemosis, pulsatile proptosis, ocular bruit
⬇️ 👁️ ⏩️ hypoxia retina ➡️ ⬇️ arterial pressure ⬆️ venous pressure and IOP
CN6 palsy
Proptosis best evaluate by
T2 coronal will 🔺 recuts m vs superior opthA v
Imaging
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.
Huber maneuver
lateral view, inject VA and manually compress affected carotid. Helps identify upper extent of fistula, multiple fistulous openings, and complete transection of ICA
Mehringer-Hieshima maneuver
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
Low flow or indirect CCF associated
spontaneous thrombosis50%
Indication for TX
- proptosis
- visual loss
- cranial nerve VI palsy
- intractable bruit
- severely ⬆️ IOP intraocular pressure
- increased filling of cortical veins on angiography
TX
Low flow , spontaneous thrmbosis , f/ vision 👀 VA and IOP < 25
If sx progressive ⬇️⬇️👀 urgent 🚨 TX ( embolization)
Compression occlude CCF about 30% ➡️ use CI hand 🖐️
Target 🎯 fromTX
Preserve 👀
Tx choices
Direct coil or clip
Indirect coli
Route for embolization
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
Complication
Injury to the fragile vein due to ballon catheter
High direct CCF
Min trunk involve CCF
meningo-hypophyseal trunk (most constant) and the inferolateral trunk.
Iatrogenic cause of CCF
Iatrogenic may be due to craniotomy, carotid endarterectomy, transsphenoidal/sinus surgery, endovascular procedures,
Common population
Traumatic CCF young
Indirect CCF / Spontnouse encounters 6 and 7 decades and female
engorged superior ophthalmic vein sign ( > 4 mm ) DDX
orbital pseudotumor, cavernous meningioma and Grave’s ophthalmopathy
If parent artery is damage
concern exists regarding catheterization of a disrupted vesse➡️ surgical option is best
mainstay of treatment of direct CCFs.
Detachable coils ➡️ advanced ability to be retrieved in the event of inadequate placement.
TVE Transvenous endovascular
Barrow type B CCFs
because of the risk of reflux of embolizate into the ICA.
Radiosurgery CCF effective in
Low-flow indirect CCFs.
High improv,ent in visual sx chemosis and proptosis
When combined radiosurgery and embolization strategy,
