Dr. Levine of the SUNY Health Science Center at Brooklyn has no relevant financial relationships to disclose.)
Carotid-cavernous fistulas are abnormal connections between the cavernous sinus and the internal carotid artery, external carotid artery, their branches, or both. There are 2 broad categories of carotid-cavernous fistulas—direct and indirect—each of which has a markedly different clinical presentation. In this article, the author discusses the clinical presentation, pathogenesis, and methods of diagnosis for this disease entity. This article provides an in-depth review of the current treatments for carotid-cavernous sinus fistulas, including the endovascular repair via transarterial or transvenous embolization.
• Carotid-cavernous sinus fistulas are communications between the cavernous sinus and the carotid arterial system.
• “Direct” carotid-cavernous sinus fistulas are abnormal communications between the internal carotid artery and the cavernous sinus, whereas “indirect” carotid-cavernous fistulas are aberrant connections between the branches of either the internal or external carotid arterial system or both and the cavernous sinus.
• “Direct” carotid-cavernous sinus fistulas are typically caused by head trauma or a ruptured cavernous carotid aneurysm and present in a dramatic fashion with proptosis, ophthalmoplegia, and loss of vision. “Indirect” or “dural” carotid-cavernous fistulas typically present in elderly women with hypertension in a more subtle fashion. Most of the time, both types of carotid-cavernous sinus fistulas can be closed successfully with modern neuro-interventional techniques.
Historical note and terminology
Carotid-cavernous fistulas are abnormal communications between the cavernous sinus and the carotid arterial system, which includes the internal carotid artery, external carotid artery, and their meningeal branches. Historically, carotid-cavernous fistulas have been classified into 2 broad categories: direct and indirect. “Direct” or “high flow” carotid-cavernous fistulas are defined as direct connections between the internal carotid artery and cavernous sinus, whereas “indirect” or “dural” carotid-cavernous fistulas are characterized by connections between the meningeal branches of the internal carotid artery or external carotid artery and the cavernous sinus. A more specific anatomical-angiographic classification for carotid-cavernous fistulas was proposed by Barrow and colleagues who differentiated between 4 types of carotid-cavernous fistulas (Barrow et al 1985). Type A is a direct fistula between the cavernous internal carotid artery and cavernous sinus and is most often caused by a traumatic tear in the arterial wall or a rupture of an cavernous carotid aneurysm.
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