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Caroticocavernous Fistula Workup

  • Author: Michael G Nosko, MD, PhD; Chief Editor: Brian H Kopell, MD  more...
 
Updated: Oct 28, 2015
 

Laboratory Studies

Lab studies include the following:

  • Routine preangiography workup to evaluate coagulation and renal function prior to delivering contrast dye includes the following:
    • CBC count
    • Platelets
    • PT and PTT
  • Electrolytes
  • BUN
  • Creatinine
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Imaging Studies

Imaging studies include the following:

  • Selective carotid angiography
    • Diagnostic test of choice
    • Helps confirm diagnosis
    • Helps determine type classification
    • Provides therapeutic capability
    • An angiogram is depicted in the image below.
      Panel A is an angiogram of caroticocavernous fistuPanel A is an angiogram of caroticocavernous fistula showing filling of the cavernous and circular sinuses. Panel B shows a post-Guglielmi detachable coil, ie, coiling of the fistula. The red arrow points to coils within the cavernous and circular sinuses after obliteration of the fistula.
  • CT scan of orbit
    • Contrast CT scan of the orbit - Helps establish diagnosis
    • May demonstrate proptosis, swelling of extraocular muscles, and dilation of superior ophthalmic vein[4]
  • Orbital ultrasound - Demonstrates same findings as CT scan
  • In a study of time-resolved magnetic resonance angiography (MRA) in 6 patients with carotid-cavernous fistulas, typical morphological findings (including enlargement of the superior ophthalmic vein, exophthalmos) were found in all cases. According to the authors, time-resolved MRA may provide relevant hemodynamic information to help plan interventional treatment.[5]
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Other Tests

 

Complete ophthalmologic workup includes the following:

  • Visual acuity
  • Pupillary function
  • Intraocular pressure
  • Funduscopy (direct and indirect)
  • Gonioscopy
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Contributor Information and Disclosures
Author

Michael G Nosko, MD, PhD Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Congress of Neurological Surgeons, Canadian Neurological Sciences Federation, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ryszard M Pluta, MD, PhD Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences, Poland; Clinical Staff Scientist, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH); Fishbein Fellow, JAMA

Ryszard M Pluta, MD, PhD is a member of the following medical societies: Polish Society of Neurosurgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, International Parkinson and Movement Disorder Society, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from St Jude Neuromodulation for consulting; Received consulting fee from MRI Interventions for consulting.

Additional Contributors

Duc Hoang Duong, MD Professor, Chief Physician, Departments of Neurological Surgery and Neuroscience, Epilepsy Center, Charles Drew University of Medicine and Science

Duc Hoang Duong, MD is a member of the following medical societies: American Neurological Association, Congress of Neurological Surgeons, North American Skull Base Society

Disclosure: Nothing to disclose.

References
  1. Barrow DL, Spector RH, Braun IF. Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg. 1985 Feb. 62(2):248-56. [Medline].

  2. Karaman E, Isildak H, Haciyev Y, Kaytaz A, Enver O. Carotid-cavernous fistula after functional endoscopic sinus surgery. J Craniofac Surg. 2009 Mar. 20(2):556-8. [Medline].

  3. Hieshima GB, Cahan LD, Mehringer CM. Spontaneous arteriovenous fistulas of cerebral vessels in association with fibromuscular dysplasia. Neurosurgery. 1986 Apr. 18(4):454-8. [Medline].

  4. Bacon KT, Duchesneau PM, Weinstein MA. Demonstration of the superior ophthalmic vein by high resolution computed tomography. Radiology. 1977 Jul. 124(1):129-31. [Medline].

  5. Seeger A, Kramer U, Bischof F, Schuettauf F, Ebner F, Danz S, et al. Feasibility of Noninvasive Diagnosis and Treatment Planning in a Case Series with Carotid-Cavernous Fistula using High-Resolution Time-Resolved MR-Angiography with Stochastic Trajectories (TWIST) and Extended Parallel Acquisition Technique (ePAT 6) at 3 T. Clin Neuroradiol. 2015 Sep. 25 (3):241-7. [Medline].

  6. Rodrigues T, Willinsky R, Agid R, TerBrugge K, Krings T. Management of dural carotid cavernous fistulas: a single-centre experience. Eur Radiol. 2014 Dec. 24 (12):3051-8. [Medline].

  7. De Renzis A, Nappini S, Consoli A, Renieri L, Limbucci N, Rosi A, et al. Balloon-assisted coiling of the cavernous sinus to treat direct carotid cavernous fistula. A single center experience of 13 consecutive patients. Interv Neuroradiol. 2013 Sep. 19 (3):344-52. [Medline].

  8. Dandy WE, Follis RH Jr. On the pathology of carotid-cavernous aneurysms (pulsating exophthalmos). Am J Ophthalmol. 1941. 24:365-385.

  9. Debrun GM, Vinuela F, Fox AJ. Indications for treatment and classification of 132 carotid-cavernous fistulas. Neurosurgery. 1988 Feb. 22(2):285-9. [Medline].

  10. Hamby WB. Carotid-cavernous fistula. Springfield, Ill: Charles C Thomas. 1966.

  11. Newton TH, Hoyt WF. Dural arteriovenous shunts in the region of the cavernous sinus. Neuroradiology. 1970. 1:71-81.

  12. Pan HC, Sun MH, Sheehan J, Sheu ML, Chen CC, Lee HT. Radiosurgery for dural carotid-cavernous sinus fistulas: Gamma Knife compared with XKnife radiosurgery. J Neurosurg. 2010 Dec. 113 Suppl:9-20. [Medline].

  13. Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg. 1974 Aug. 41(2):125-45. [Medline].

  14. Walker AE, Allegre GE. Carotid-cavernous fistulas. Surgery. 1956. 39:411-422.

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Type-D caroticocavernous fistula: the eye demonstrates proptosis, chemosis, and scleral edema. The patient is unable to close the eye, exposing the cornea to dehydration and potential trauma.
Panel A is an angiogram of caroticocavernous fistula showing filling of the cavernous and circular sinuses. Panel B shows a post-Guglielmi detachable coil, ie, coiling of the fistula. The red arrow points to coils within the cavernous and circular sinuses after obliteration of the fistula.
This is a diagrammatic representation of the 4 types of caroticocavernous fistulas. ICA is the internal carotid artery; ECA is the external carotid artery.
 
 
 
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