J Cerebrovasc Endovasc Neurosurg.  2022 Dec;24(4):356-365. 10.7461/jcen.2022.E2022.05.004.

Carotid cavernous fistula: Redefining the angioarchitecture

• Mishra K
• Kumar V
• V
• Gandhi A
• Srivastava T

• KMID: 2537320
• DOI: http://doi.org/10.7461/jcen.2022.E2022.05.004

Abstract

Objective
Numerous classification schemes have been used for carotid cavernous fistula (CCF), each describing some aspect of the disease process but none of them provides a complete description of the fistula including its clinical features, natural history, arterial and venous architecture.
Methods
Retrospective clinical and radiological review was done for all the patients diagnosed with CCF and treated at our institute. The CCF were classified according to the proposed API-ACE classification along with Barrow and Thomas classification.
Results
Overall 28 patients (M=21, F=7) were diagnosed and treated during the 6-year period. 89.2% of CCF developed following an episode of head injury. Orbital symptoms were the most common presenting complaints. Barrows type A was the most predominant subtype (n=24) and most of the patients (n=23) demonstrated decreased ipsilateral carotid filling. Combined anterior and posterior drainage pattern was the most common drainage pattern and anterior drainage was more commonly observed than posterior drainage.
Conclusions
API-ACE classification helps to better understand and classify the angioarchitecture of CCF which could help better understand the clinical manifestations and guide in appropriate endovascular approach selection for treatment.

Keyword

Carotid cavernous fistula (CCF); Thomas classification; Venous angioarchitecture

Figure

• 

  Fig. 1. (A) Angiogram in a post-traumatic CCF case showing communication of cavernous sinus with right ICA (high flow, direct) and right ECA. (B) Left ICA angiogram showing two sites of fistulous communication with cavernous sinus. CCF, carotid cavernous fistula; ICA, internal carotid artery; ECA, external carotid artery

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  Fig. 2. Diagrammatic representation of components of API-ACE classification scheme. (A) Sketch showing CCF in relation to ICA with predominantly anterior drainage (A1) into the superior ophthalmic vein (SOV). (B) CCF with predominantly posterior drainage (P1) into the superior and inferior petrosal sinus (SPS and IPS) in relation to the petrous bone. (C) CCF with inferior venous drainage (I1) into the pterygoid venous plexus through foramen in the skull base. (D) Arterial communication with the ICA A1- direct communication with ICA; A0- arterial communication via a branch of ICA. (E) CCF causing venous hypertension and reversal of blood flow in the cortical vein via superior sagittal and spheno-petrosal sinus (C1). (F) CCF arising from meningeal branch of external carotid artery (E1). CCF, carotid cavernous fistula; ICA, internal carotid artery

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  Fig. 3. Schematic representation of API-ACE classification scheme and the distribution of cases in our series. ICA, internal carotid artery; ECA, external carotid artery

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  Fig. 4. Direct, high flow CCF with no ECA contribution, with both anterior and posterior ± inferior drainage pattern. (A) Right ICA lateral angiogram showing API- A1 C0 E0 (B) Right ICA lateral angiogram showing API- A1 C1 E0. CCF, carotid cavernous fistula; ECA, external carotid artery; ICA, internal carotid artery

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  Fig. 5. (A) Direct, high flow CCF with no ECA contribution, with predominant posterior venous drainage. Left ICA lateral angiogram showing PI- A1 C1 E0. (B) Direct, high flow CCF with no ECA contribution, with anterior venous drainage. Right ICA angiogram demonstrating A- A1 C0 E0 type of CCF. CCF, carotid cavernous fistula; ECA, external carotid artery; ICA, internal carotid artery

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