Imaging findings and outcomes in patients with carotid cavernous fistula at Inkosi Albert Luthuli Central Hospital in Durban

BACKGROUND: Carotid cavernous fistulas (CCFs) are relatively uncommon and are difficult to diagnose clinically. Radiological imaging plays a significant role in making the diagnosis with recent advances improving the ability of radiologists to diagnose the condition. Despite these developments, digital subtracted angiography (DSA) remains the gold standard in diagnosing CCFs and simultaneously provides the opportunity for intervention. OBJECTIVES: To determine the imaging findings of patients presenting to Inkosi Albert Luthuli Central Hospital (IALCH) with a CCF and to assess the outcome of endovascular intervention. METHOD: We reviewed the electronic records and archived imaging data of consecutive patients diagnosed with CCF between January 2003 and May 2016 at IALCH, in particular, the imaging findings, intervention and subsequent outcomes. RESULTS: Computed tomography (CT) was the most utilised imaging modality prior to patients undergoing DSA. A dilated superior ophthalmic vein (96%) was the most prevalent imaging finding on axial imaging. At DSA, all except two patients had high-flow fistulas. The fistulas predominantly drained anteriorly (69.44%) and a cavernous internal carotid artery aneurysm was identified in eight patients. Occlusion of the fistula was attained in all patients that were compliant with follow-up and underwent intervention (n = 36, 100%), but parent artery sacrifice was required in 10 cases (27.78%). CONCLUSION: A wide range of imaging modalities can be used in the workup of a CCF. CT is currently the most accessible modality in our setting, with limited access to magnetic resonance imaging. On axial imaging, a dilated superior ophthalmic vein is the commonest finding. Classification of a fistula according to flow dynamics and noting the presence of aneurysms or pseudoaneurysms was found to be more practical in comparison to the traditional Barrow’s classification. Management outcomes at our institution compare well with available local and international data.