Relationship of clinical presentation and angiographic findings in patients with indirect cavernous carotid fistulae

Alexander, Matthew; Halbach, Van V.; Hallam, Danial K.; Cooke, Daniel L; Ghodke, Basavaraj; Dowd, Christopher F.; Amans, Matthew R; Hetts, Steven W.; Higashida, Randall T.; Meyers, Philip M.

doi:10.1136/neurintsurg-2018-014421

Cited by 9 publications

(9 citation statements)

References 15 publications

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“…They postulated that penetration of the liquid agent into the matrix of the coil mass enables complete obliteration with less glue material (3). Alexander and colleagues found out that in their study cohort of patients with indirect CCF the complication rate was significantly lower when there was a combined use of Onyx and coils instead of Onyx as the sole embolic agent (26). We described a combination of those two materials in 25 cases of our study cohort (25/59, 42.4%).…”

Section: Discussionmentioning

confidence: 79%

Management of carotid cavernous fistulas: A single center experience

Alatzides

Opitz

et al. 2023

Front. Neurol.

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PurposeMultimodal endovascular therapy (EVT) of carotid cavernous fistula (CCF) with different approaches and a variety of available embolization material enable high occlusion rates with good clinical and functional outcome but until now there is still little evidence available. This retrospective single-center study aims to evaluate EVT of CCF with different neuroendovascular techniques regarding occlusion rates, complications and outcomes.Materials and methodsFrom 2001 to 2021 59 patients with CCF were treated at our tertiary university hospital. Patient records and all imaging data including angiograms were reviewed for demographic and epidemiological data, symptoms, fistula type, number of EVTs, complications of EVT, type of embolic materials, occlusion rates and recurrences.ResultsEtiology of the CCF were spontaneous (41/59, 69.5%) post-traumatic (13/59, 22%) and ruptured cavernous aneurysms (5/59, 8.5%). Endovascular therapy was completed in one session in 74.6% (44/59). Transvenous access was most frequent (55.9% 33/59) followed by transarterial catheterization in 33.9% (20/59) and a combination of both (6/59, 10.2%). Exclusively coils were used in 45.8% (27/59), a combination of ethylene vinyl alcohol (EVOH) copolymer (Onyx) and coils in 42.4% (25/59). Complete obliteration was achieved in 96.6% of patients (57/59) with an intraprocedural-related complication rate of 5.1% (3/59) and no mortality.ConclusionEndovascular therapy of CCF has been shown to be safe and effective with high cure rates and low rates of intraprocedural complications and morbidity even in complex scenarios.

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Section: Discussionmentioning

confidence: 79%

Management of carotid cavernous fistulas: A single center experience

Alatzides

Opitz

et al. 2023

Front. Neurol.

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“…Arteriovenous fistulas are abnormal connections between arteries and veins. Dural arteriovenous fistulas (dAVFs) are typically between dural arteries and a venous sinus, most commonly at the transverse-sigmoid sinus, marginal sinus and/or condylar veins, cavernous sinus, or vertebral venous plexus . Dural arteriovenous fistulas are sometimes associated with venous sinus thrombosis, which may occur following an infection, trauma, or surgery.…”

Section: Discussion: Diagnosis By Categorymentioning

confidence: 99%

Diagnostic Approach to Pulsatile Tinnitus

Narsinh

Hui

Saloner

et al. 2022

JAMA Otolaryngol Head Neck Surg

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ulsatile tinnitus (PT) is a symptom referring to an abnormal perception of rhythmic sound without an extracorporeal source, affecting between 3 and 5 million Americans. [1][2][3][4] Pulsatile tinnitus can have a negative effect on patients' psychological and physical health, leading to insomnia, anxiety, depression, and poor concentration. 5 Seeking an underlying cause of PT is essential because many of them pose a significant risk of stroke, blindness, or deafness. Hence, some of the causes of PT warrant treatment to mitigate risk to cerebrovascular, otologic, or ophthalmologic health, whereas other causes may be treated to address the symptom itself and its psychiatric comorbidities. This review describes our diagnostic approach to PT. Rather than providing a detailed list of possible diagnoses, our goal is to provide an approach for physicians to evaluate patients with PT. ObservationsOur diagnostic approach categorizes causes of PT into structural, metabolic, and vascular groups (Table ). This categorization facilitates appropriate and practical diagnostic evaluation, referral, and treatment in a patient-centric fashion rather than focusing on anatomic compartments alone. PathophysiologyPulsatile tinnitus often originates from vascular structures in the head or neck in proximity to the cochlea. 6 Alternatively, normal sounds within the body can be perceived more intensely because of inner ear alterations to sound conduction, or loss of masking ability. Clinical PresentationUnlike nonpulsatile tinnitus, an underlying cause of PT can be identified in more than 70% of patients with a thorough evaluation. 7 Careful attention to a patient's medical history and examination can often lead to a correct diagnosis. The initial clinical counter should record the PT's onset, progression, severity, and exacerbating or mitigating positions, movements, or other factors. The history should also include any associated symptoms, particularly hearing loss, headache (also including any positional component), vision changes, vertigo, anxiety, or depression, and, crucially, assess the effect on the patient's life. For example, in patients with a history of recent neck manipulation, arterial dissection should be suspected and one should have a low threshold to initiate low-dose aspirin for stroke prevention, even if the diagnosis is not yet confirmed. The PT itself should be further characterized by synchronicity with the patient's heartbeat and pitch. Pulse-synchronous PT is often related to abnormal vascular flow in structures near the cochlea. 6 Specifically, abnormal blood flow in the transverse sinus, sigmoid sinus, internal jugular vein, or condylar veins can stimulate the inner hair cells of the cochlea and result in PT. However, pulse-asynchronous PT (without concomitant atrial fibrillation) is usually associated with a mechanical rather than a vascular cause. Specifically, normal sounds within IMPORTANCE Pulsatile tinnitus is a debilitating symptom affecting millions of Americans and can be a harbinger of hemorrhagic or is...

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“…Alexander et al 7 found that the majority of patients with indirect CCF were females with mean age of 61 years, with mean duration from symptom onset to diagnosis of 234 days. Clinical signs and symptoms of CCF are conjunctival chemosis and injection, proptosis, ophthalmoplegia, pulsating exophthalmos, diplopia, orbital pain, bruits, increased IOP, and decreased vision.…”

Section: Discussionmentioning

confidence: 99%

“…Intracranial hemorrhage or hemorrhagic infarcts are rare but dangerous complications of CCF and are associated with cortical venous reflux (CVR). 7 , 9 , 10 Cortical venous reflux has been found to be more common in patients with diplopia, cranial nerve palsy, elevated IOP, chemosis, and bruit. 7 Traditional 4-vessel angiography (digital subtraction angiography) is the gold standard to diagnose CCF and CVR, which may show tortuous and engorged veins, delayed appearance of the veins and focal staining, along the region of CVR in the venous phase of vertebral or internal carotid arteriography.…”

Section: Discussionmentioning

confidence: 99%

“… 7 , 9 , 10 Cortical venous reflux has been found to be more common in patients with diplopia, cranial nerve palsy, elevated IOP, chemosis, and bruit. 7 Traditional 4-vessel angiography (digital subtraction angiography) is the gold standard to diagnose CCF and CVR, which may show tortuous and engorged veins, delayed appearance of the veins and focal staining, along the region of CVR in the venous phase of vertebral or internal carotid arteriography. 9 Additional imaging clues to aid diagnosis include enlarged SOVs, thick extraocular muscles, enlarged cavernous sinus showing convexity of the lateral wall on brain CT and Magnetic Resonance Imaging (MRI), increased signal intensity of the brain parenchyma in the region and CVR on brain MRI, and decreased cerebral blood flow on the region of CVR on single-photon emission computerized tomography (SPECT).…”

Section: Discussionmentioning

confidence: 99%

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Bilateral Carotid-Cavernous Fistula: A Diagnostic and Therapeutic Challenge

Sharma

Ponder

Kamran

et al. 2022

Journal of Investigative Medicine High Impact Case Reports

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Carotid-cavernous fistula (CCF) is an aberrant communication between the main trunk or branches of carotid artery and the cavernous sinus. Most of the cases of CCF occur following head trauma, but congenital and spontaneous cases have been reported. We report an interesting case of bilateral CCF with no history of trauma, thus most likely spontaneous form. Since it is rare, it was a diagnostic challenge. The suspicion of this diagnosis was made due to clinical features of headache, signs of increased Intracranial Pressure (ICP) (nausea, vomiting, and worsening headaches during Valsalva), exophthalmos, periorbital edema, periorbital erythema, chemosis, and conjunctival injection in both eyes. It was diagnosed with a 4-vessel angiography (digital subtraction angiography) which is the gold standard and was managed successfully with endovascular coil embolization.

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Relationship of clinical presentation and angiographic findings in patients with indirect cavernous carotid fistulae

Cited by 9 publications

References 15 publications

Management of carotid cavernous fistulas: A single center experience

Management of carotid cavernous fistulas: A single center experience

Diagnostic Approach to Pulsatile Tinnitus

Bilateral Carotid-Cavernous Fistula: A Diagnostic and Therapeutic Challenge

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