Current modalities for diagnosing carotid cavernous fistula (CCF) are inaccurate in analysing retinal microcirculations and nerve fibre changes. Retinal microvascular and neural alterations occur in CCF patients and can be quantitatively measured using optical coherence tomography angiography (OCTA). We measured the neurovascular changes in the eyes of CCF patients and used OCTA as a supplementary method.
This cross-sectional study studied 54 eyes of 27 unilateral CCF subjects and 54 eyes of 27 healthy age- and sex-matched controls. OCTA parameters in the macula and optic nerve head (ONH) were analysed using a one-way analysis of variance with further Bonferroni corrections. Parameters with statistical significance were included in a multivariable binary logistic regression analysis and receiver operating characteristic (ROC) curves were generated.
There was significantly less deep-vessel density (DVD) and ONH-associated capillary density in both eyes of CCF patients than in controls, while the differences between the affected and contralateral eyes were insignificant. The retinal nerve fibre layer and ganglion cell complex thickness were lower in the affected eyes than in the contralateral or controlled eyes. ROC curves identified DVD and ONH-associated capillary density as significant parameters in both eyes of CCF patients.
The retinal microvascular circulation was affected in both eyes of unilateral CCF patients. Microvascular alterations occurred before retinal neural damage. This quantitative study suggests a supplementary measurement for diagnosing CCF and detecting early neurovascular impairments.

UNASSIGNED: To compare the sensitivities of T2-weighted image (T2WI) and susceptibility-weighted imaging (SWI) in detecting cerebral arteriovenous fistula (AVF), cerebral arteriovenous malformation (AVM), and carotid-cavernous sinus fistula (CCF), and to qualitatively evaluate single-echo SWI (s-SWI) and multi-echo SWI (m-SWI) in characterizing vascular lesions.
UNASSIGNED: From January 2016 to December 2021, cerebral angiography-proven lesions were recruited. The sensitivities of T2WI and SWI in detecting vascular lesions were compared using McNemar\'s test. Qualitative evaluations of s-SWI and m-SWI were categorized to be of poor, average, or good quality and compared using Fisher\'s exact test.
UNASSIGNED: A total of 24 patients (mean age: 61 years, 12 female, and 12 male) were enrolled. Twenty patients underwent s-SWI or m-SWI, and four patients underwent both. AVF, AVM, and CCF were diagnosed in 10, 11, and 3 patients, respectively. SWI demonstrated higher sensitivity compared to that of T2WI (82.1% vs. 53.6%, p = 0.013). m-SWI showed better image quality compared to that of s-SWI (good quality, 83.3% vs. 25.0%, p = 0.009).
UNASSIGNED: SWI demonstrated a higher sensitivity for detecting cerebral arteriovenous shunts compared to that of T2WI. m-SWI exhibited better image quality compared to that of s-SWI in characterizing vascular lesions.
UNASSIGNED: 뇌동정맥루(arteriovenous fistula; 이하 AVF), 뇌동정맥기형(arteriovenous malformation; 이하 AVM), 경동맥해면정맥동루(carotid-cavernous sinus fistula; 이하 CCF) 등 뇌동정맥단락을 진단하는 데 있어서, T2 강조영상(T2-weighted imaging; 이하 T2WI)과 자화율 강조영상(susceptibility-weighted imaging; 이하 SWI)의 민감도를 비교하고, 단일 에코(single-echo) SWI(이하 s-SWI)와 다중 에코(multi-echo) SWI (이하 m-SWI)의 전반적인 영상 질을 비교하고자 하였다.
UNASSIGNED: 2016년부터 2021년까지 뇌혈관조영술로 입증된 뇌동정맥단락을 조사하였다. 뇌동정맥단락에 대한 T2WI와 SWI의 민감도를 McNemar’s Test를 이용하여 비교하였다. s-SWI와 m-SWI의 영상 질을 나쁨, 보통, 좋음으로 분류하고 Fisher’s exact test를 이용하여 그 비율을 비교하였다.
UNASSIGNED: 총 24명의 환자(중위 연령: 61세, 여성: 12명, 남성: 12명)가 연구에 포함되었다. 그중 4명은 s-SWI와 m-SWI 두 가지의 SWI로, 나머지 20명은 이 중 한 가지의 SWI로 검사하였다. 10명은 AVF, 11명은 AVM, 3명은 CCF로 진단되었고, 이와 같은 뇌동정맥단락에 대해, SWI는 T2WI 보다 유의하게 높은 민감도를 보였다(82.1% vs. 53.6%, p = 0.013). m-SWI는 s-SWI 보다 좋은 영상 질의 비율이 유의하게 높았다(83.3% vs. 25.0%, p = 0.009).
UNASSIGNED: SWI는 T2WI 보다 뇌동정맥단락을 더 민감하게 진단해 낼 수 있었으며, m-SWI는 s-SWI보다 혈관질환을 평가하는데 더 좋은 영상 질을 보였다.

BACKGROUND: More data is needed on the short- and medium-term efficacy and safety of the Willis covered stent in treating distal internal carotid artery (DICA) aneurysms and vertebral artery dissecting aneurysms (VADAs).
METHODS: Records of all 42 patients with DICA aneurysms or VADAs treated with the Willis covered stents at our institute between July 2014 and January 2019 were retrospectively examined. The patients\' demographic information, symptoms, diagnosis, treatment procedure, immediate and follow-up clinical and angiographic outcomes were extracted.
RESULTS: 46 Willis covered stents were successfully implanted in all of the 42 patients (total 43 aneurysms). Immediate complete aneurysm occlusion was achieved in 37 patients (38 aneurysms) (88.4%), and endoleak occurred to 5 patients (5 aneurysms) (11.6%). 2 patients died post-operatively from procedure-related complications, another one died from reasons unrelated to the procedure. Among the remaining 39 patients, non-lethal complications occurred in 4 patients including ptosis and diplopia of the right eye, intra-operative hemorrhage and carotid cavernous fistulas (CCF). Angiographic and clinical follow-ups (means ± standard deviation: 8.8 ± 5.3 months) were done for 32 patients (33 aneurysms). Complete occlusion was maintained in all of the 33 aneurysms. 2 of the 32 patients had significant though asymptomatic parent artery (PA) occlusion. No ischemic or hemorrhagic event occurred during the follow-up period. The modified Rankin Scale (mRS) score was 0 in 31 patients and 1 in the remaining 1 patient.
CONCLUSIONS: The Willis covered stent could be a safe and effective treatment for complex DICA aneurysms with excellent durability. In addition, the Willis covered stent treated all of the 3 cases of VADAs in the study with complete success without any complications, however, as the number of the VADA cases was small, more cases are needed to further confirm the efficacy and safety of the Willis covered stent in treating VADAs.

BACKGROUND: A non-invasive, reliable imaging modality that characterizes cavernous sinus dural arteriovenous fistula (CSDAVF) is beneficial for diagnosis and to assess resolution on follow-up.
OBJECTIVE: To assess the utility of 3D time-of-flight (TOF) and silent magnetic resonance angiography (MRA) for evaluation of CSDAVF from an endovascular perspective.
METHODS: This prospective study included 37 patients with CSDAVF, who were subjected to digital subtraction angiography (DSA) and 3-T MR imaging with 3D TOF and silent MRA. The main arterial feeders, fistula site, and venous drainage pattern were evaluated, and the results were compared with DSA findings. The diagnostic confidence scores were also recorded using a 4-point Likert scale.
RESULTS: Silent MRA correlated better for shunt site localization and angiographic classification (86% vs. 75% and 83% vs. 75%, respectively) compared to TOF MRA. The proportion of arterial feeders detected was marginally significant for silent MRA over TOF MRA sequences (92.8% vs. 89.5%; P=0.048), though for veins both were comparable. Sensitivity of silent MRA was higher for identification of cortical venous reflux (CVR) (90.9% vs. 81.8%) and deep venous drainage (82.4% vs. 64.7%), while specificity was >90% for both modalities. The overall diagnostic confidence score fared better for silent MRA for venous assessment (P < 0.001) as well as fistula point identification (P < 0.001), while no significant difference was evident with TOF MRA for arterial feeders (P=0.06).
CONCLUSIONS: Various angiographic components of CSDAVF could be identified and delineated by 3D TOF and silent MRA, though silent MRA was superior for overall diagnostic assessment.

OBJECTIVE: The aim of this study was to determine local diagnostic reference levels (DRLs) during endovascular diagnostics and therapy of carotid-cavernous fistulas (CCF).
METHODS: In a retrospective study design, DRLs, achievable dose (AD) and mean values were assessed for all patients with CCF undergoing diagnostic angiography (I) or embolization (II). All procedures were performed with the flat-panel angiography system Allura Xper (Philips Healthcare). Interventional procedures were differentiated according to the type of CCF and the type of procedure.
RESULTS: In total, 86 neurointerventional procedures of 48 patients with CCF were executed between February 2010 and July 2021. The following DRLs, AD and mean values could be determined: (I) DRL 215 Gy ∙ cm2, AD 169 Gy ∙ cm2, mean 165 Gy ∙ cm2; (II) DRL 350 Gy ∙ cm2, AD 226 Gy ∙ cm2, mean 266 Gy ∙ cm2. Dose levels of embolization were significantly higher compared to diagnostic angiography (p < 0.001). No significant dose difference was observed with respect to the type of fistula or the embolization method.
CONCLUSIONS: This article reports on diagnostic and therapeutic DRLs in the management of CCF that could serve as a benchmark for the national radiation protection authorities. Differentiation by fistula type or embolization method does not seem to be useful.

Endovascular embolization nowadays is a well-established treatment option for direct carotid cavernous fistulas (dCCF, Barrow Type A). There are many publications on the complication and success rates of this method. However, little is known on the patients´ opinion on the treatment result after several years. We report on this issue also including the \"pioneer patients\" treated almost two decades ago.
We retrospectively reviewed the records of all patient (n = 25) with a more than 24 months follow-up interval after endovascular treatment of a dCCF at our institution from 01/1999 to 08/2018. We determined primary therapy success, complication rate, state of the fistula in the last imaging follow-up and quoted the patient\'s subjective perception of the long-term treatment success using a standardized interview form.
Occlusion rate in the last imaging follow up was 96% (24/25) with a complication rate of 8% (2/25). The response rate on our interview request was 96% (24/25) with a rate of considered feedback of 84% (21/25 patients). Duration of our observation interval for the patient reported outcome was 143 months / 11 years (median, range: 35-226 m / 2-18 y). Most of them (21/25, 84%) felt they benefited from the treatment.
Endovascular supply of dCCF is a highly effective treatment method leading to a sustainable therapy success with long-lasting stable subjective benefit even to our \"pioneer patients\" treated almost two decades ago.

Endovascular treatment of complex traumatic direct carotid-cavernous fistulas (TDCCFs) is a challenge.
To evaluate the long-term efficacy of the Willis covered stent in endovascular treatment of complex TDCCFs, focusing on reconstruction and preservation of the internal carotid artery.
During the past 8 years, 25 patients with 27 TDCCFs who previously had unsuccessful treatment of fistulas with detachable balloons received endovascular treatment with Willis covered stents. The efficacy, complications, in-stent stenosis, angiographic, and clinical follow-up results were evaluated retrospectively between 6 and 88 months (mean, 43.8 months) after the stent placement.
The technical success rate of stenting placement was 100%. Forty-four Willis covered stents were implanted into the target artery of 27 TDCCFs. Complete exclusion was achieved in 16 patients with 17 TDCCFs immediately after the stent placement, with transient endoleaks in 10 TDCCFs. Redilation was performed in 6 TDCCFs, and additional stents were implanted in the other 4 TDCCFs for endoleak exclusion. The initial angiographic results showed complete exclusion of fistulas with preservation of the internal carotid artery in 24 patients with 26 TDCCFs. One patient in whom complete occlusion initially was achieved subsequently experienced a delayed endoleak, which required placement of an additional stent. The angiographic follow-up results (mean, 30.3 months) demonstrated complete exclusion in all 27 TDCCFs, with patency of internal carotid artery in 23 patients. The clinical follow-up demonstrated a full recovery in 23 patients and improvement in 2 patients.
The use of Willis covered stents was confirmed to be effective, safe, and a curative approach for endovascular treatment of complex TDCCFs and internal carotid artery reconstruction.
DB, detachable balloonEVT, endovascular treatmentICA, internal carotid arteryn-BCA, N-butyl cyanoacrylateTDCCF, traumatic direct carotid-cavernous fistula.

Carotid-cavernous sinus fistula (CCF) is a rare complication occurring after the Le Fort osteotomy. We aimed to elucidate the cause of CCF in the Le Fort osteotomy.
METHODS: Eleven fresh cadavers were used. After craniotomy, a Le Fort III bipartition osteotomy was then performed. On the left side, both the lateral wall of the maxilla and the pterygomaxillary junction (PMJ) were divided, in addition to the conventional osteotomy line. On the right side, those parts were kept intact. After the osteotomy, a tensiometer was fixed to the skull base. The sensor was linked with the wall of the carotid artery in the cavernous portion. A down-fracture was then performed initially from the left, followed by the right. Tensile force data of both sides were recorded.
RESULTS: In all cases, a higher tensile load was observed on the right side compared to the left side. In right side, two skull base fractures complexed with high pterygoid process fractures, and nine pure high fractures of the pterygoid process were identified.
CONCLUSIONS: During down-fracture, the wall of the carotid artery experiences significant tensile load. The tensile load on the arterial wall may collapse the fine branches of the carotid artery in the cavernous portion.

We report our experience in treatment of traumatic direct carotid cavernous fistula (CCF) via endovascular intervention. We hereof recommend an additional classification system for type A CCF and suggest respective treatment strategies. Only type A CCF patients (Barrow\'s classification) would be recruited for the study. Based on the angiographic characteristics of the CCF, we classified type A CCF into three subtypes including small size, medium size and large size fistula depending on whether there was presence of the anterior carotid artery (ACA) and/or middle carotid artery (MCA). Angiograms with opacification of both ACA and MCA were categorized as small size fistula. Angiograms with opacification of either ACA or MCA were categorized as medium size fistula and those without opacification of neither ACA nor MCA were classified as large size fiatula. After the confirm angiogram, endovascular embolization would be performed impromptu using detachable balloon, coils or both. All cases were followed up for complication and effect after the embolization. A total of 172 direct traumatic CCF patients were enrolled. The small size fistula was accountant for 12.8% (22 cases), medium size 35.5% (61 cases) and large size fistula accountant for 51.7% (89 cases). The successful rate of fistula occlusion under endovascular embolization was 94% with preservation of the carotid artery in 70%. For the treatment of each subtype, a total of 21/22 cases of the small size fistulas were successfully treated using coils alone. The other single case of small fistula was defaulted. Most of the medium and large size fistulas were cured using detachable balloons. When the fistula sealing could not be obtained using detachable balloon, coils were added to affirm the embolization of the cavernous sinus via venous access. There were about 2.9% of patient experienced direct carotid artery puncture and 0.6% puncture after carotid artery cut-down exposure. About 30% of cases experienced sacrifice of the parent vessels and it was associated with sizes of the fistula. Total severe complication was about 2.4% which included 1 death (0.6%) due to vagal shock; 1 transient hemiparesis post-sacrifice occlusion of the carotid artery but the patient had recovered after 3 months; 1 acute thrombus embolism and the patient was completely saved with recombinant tissue plaminogen activator (rTPA); 1 balloon dislodgement then got stuck at the anterior communicating artery but the patient was asymptomatic. Endovascular intervention as the treatment of direct traumatic CCF had high cure rate and low complication with its ability to preserve the carotid artery. It also can supply flexible accesses to the fistulous site with various alternative embolic materials. The new classification of type A CCF based on angiographic features was helpful for planning for the embolization. Coil should be considered as the first embolic material for small size fistula meanwhile detachable balloons was suggested as the first-choice embolic agent for the medium and large size fistula.

This study determined the utility and accuracy of susceptibility-weighted MRI (SWI) for the detection of carotid cavernous fistulas. We retrospectively compared SWI images in nine patients (Group 1, case group) of DSA-proved carotid cavernous fistula (CCF) and 19 DSA negative cases for CCF as a control group (Group 2). Group 1 was again sub-grouped into direct and indirect types. Using uniform region-of-interest measurements, signal intensity within the superior ophthalmic vein (SOV) and the superior sagittal sinus (SSS) were measured on magnitude images of SWI. The SOV/SSS signal intensity ratio was calculated in each case and the mean values of the two groups were compared. Eleven SOV/SSS signal intensity ratios in Group 1 (7 unilateral and two bilateral CCF), 38 in Group 2 (both sides in 19 control subjects) were included. Median ± interquartile range of SOV/SSS ratios for Group 1, Group 2, indirect and direct type CCFs were 1.07 ± 0.43, 0.39 ± 0.23, 0.83 ±0.29, 1.4 ±0.38 respectively. Mann-Whitney test between Groups 1 and 2 was statistically significant with P<0.0001. All cases and controls were reliably distinguished with SOV/SSS signal intensity ratio of 0.64 as cut-off. Direct CCF cases had consistently higher ratios than indirect CCF. SWI was highly sensitive for detection and differentiation of both direct and indirect CCF. Only one case of corticovenous reflux was missed by SWI. SWI is useful for detection of CCF and to differentiate between direct and indirect CCF.