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  • Direct Carotid-Cavernous Fistula; a Complication of, and Treatment with, Flow-Diversion

    Final Number:

    Krishna Amuluru MD, Fawaz Al-Mufti MD, Stephen Hannaford BA, Chirag D. Gandhi MD, Charles J. Prestigiacomo MD, Inder Paul Singh MD

    Study Design:

    Subject Category:
    Aneurysm/Subarachnoid Hemorrhage

    Meeting: AANS/CNS Cerebrovascular Section 2016 Annual Meeting

    Introduction: The Pipeline Embolization Device (PED) (ev3, Irvine, CA) is a flow-diverting stent designed for treating complex intracranial aneurysms with challenging morphologies. Direct (Barrow type-A) carotid-cavernous fistulas (CCFs) consist of an abnormal communication between the internal carotid artery (ICA) and the cavernous sinus, arising spontaneously or secondary to trauma. Barrow type-A direct CCFs are a rare complication of PED usage, and have only been reported several weeks to months after PED deployment. Additionally, flow-diversion has recently been reported as a treatment option for direct CCFs, although its efficacy remains unclear. We report a case of an immediate CCF during PED deployment that was then successfully treated with subsequent deployment of additional PEDs.

    Methods: A 69-year-old female with a history of hypertension and 2 years of progressive right-sided vision loss presented with worsening left-sided vision. On exam, she had no light perception in the right eye, and 20/60 visual acuity in the left eye. MRI of the brain as and cerebral angiogram showed a large paraophthalmic right ICA aneurysm with mass effect on the optic chiasm. She underwent treatment of the aneurysm with flow-diversion.

    Results: The first PED was deployed across the neck of the aneurysm. On subsequent follow-up angiogram, there was decreased anterograde flow through the ICA as well as early opacification of the cavernous sinus and superior ophthalmic vein, consistent with CCF. Four additional PEDs were quickly deployed across the aneurysm neck and within the cavernous ICA with stagnation of flow into the aneurysm as well as decreased flow through the CCF. Post-procedurally, the patient had no new visual symptoms and intra-ocular pressures remained within normal limits. Follow-up angiogram at 3-months showed decreased flow through the CCF, and at 6-months showed complete resolution of the CCF.

    Conclusions: Intra-procedural development of a Barrow type-A CCF during PED deployment has never been reported. There is little data regarding usage of PED in the treatment of these direct CCFs. Our case reports both a rare complication of PED as well as the effective use of the PED for treatment of such CCFs.

    Patient Care: Our research will help physicians diagnose and treat a rare complication of flow diversion.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of recognizing and diagnosing carotid-cavernous fistula. 2) Discuss, in small groups, the complications of PED. 3) Identify novel technologies for management of CCF.


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