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Relationship of clinical presentation and angiographic findings in patients with indirect cavernous carotid fistulae
  1. Matthew David Alexander1,
  2. Van V Halbach2,
  3. Danial K Hallam3,
  4. Daniel L Cooke4,
  5. Basavaraj Ghodke3,
  6. Christopher F Dowd2,
  7. Matthew R Amans2,
  8. Steven W Hetts5,
  9. Randall T Higashida4,
  10. Philip M Meyers6
  1. 1 Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah, USA
  2. 2 Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
  3. 3 Radiology, University of Washington, Seattle, Washington, USA
  4. 4 Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
  5. 5 Radiology, UCSF, San Francisco, California, USA
  6. 6 Radiology and Neurological Surgery, Columbia University, New York, USA
  1. Correspondence to Dr Matthew David Alexander, Radiology and Biomedical Imaging, University of California San Francisco, Salt Lake City, UT 84132, USA; matthew.alexander{at}


Introduction Indirect cavernous carotid fistulae (ICCFs) can present with insidious, non-specific symptoms and prove difficult to diagnose. This study evaluates associations among ICCF symptoms and angiographic findings.

Methods A retrospective analysis was performed of prospectively maintained records at four medical centers to identify patients with ICCFs evaluated with angiography. Patient demographics, symptoms, and angiographic findings were tabulated. Univariate and multivariate analyses were conducted to identify associations among these variables.

Results Records sufficient for review existed for 267 patients evaluated with angiography. Patients were most commonly women, in the sixth or seventh decade of life, and had symptoms for months before a definitive diagnosis. The most common symptoms included proptosis, diplopia, cranial nerve palsy, and chemosis. Cortical venous reflux was most common in patients with chemosis, orbital pain, or bruit. Intracranial hemorrhage was associated with cortical reflux and bilateral inferior petrosal sinus occlusion. Patients with loss of symptoms demonstrated higher rates of inferior petrosal sinus occlusion and a trend towards rupture.

Conclusion A high index of suspicion is needed to promptly diagnose patients with ICCFs. High risk features are more common in the setting of chemosis, orbital pain, bruit, or spontaneous loss of symptoms. Patients with such symptoms warrant expedited angiographic evaluation.

  • fistula
  • orbit
  • angiography

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  • Contributors All authors participated in patient care, collected data, and edited the manuscript. Additionally, MDA analyzed the data and authored the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Institutional review board approval was obtained at all four sites prior to data collection.

  • Provenance and peer review Not commissioned; externally peer reviewed.