This study included six patients diagnosed with traumatic CCFs at our institution. The patients ranged in age from 18 to 64 years and presented with varying degrees of ophthalmologic and neurological symptoms following traumatic events such as falls or head injuries. Each patient underwent a thorough clinical evaluation, including ophthalmologic and neurological assessments, to determine the extent of vascular involvement.

All patients underwent DSA, which remains the gold standard for diagnosing CCFs. DSA provided high-resolution visualization of the arteriovenous communication between the ICA and the cavernous sinus, enabling accurate classification of the fistulas. Additional imaging modalities, including computed tomography angiography (CTA) and magnetic resonance imaging (MRI), were utilized in select cases to assess associated intracranial injuries, venous drainage patterns, and collateral circulation. All patients underwent Digital Subtraction. While DSA is essential for definitive diagnosis, non-invasive imaging techniques such as transocular ultrasound and Doppler can be valuable adjuncts for bedside pre- and postoperative assessment without radiation exposure, though these were not systematically applied in the present study.

Endovascular embolization was the primary treatment modality for all patients. The choice of embolization technique was tailored based on the anatomical characteristics of the fistula, vascular access, and hemodynamic factors. The following treatment strategies were employed:

Coil Embolization: In cases where direct access to the fistula was feasible, detachable coils were used to occlude the arteriovenous shunt while preserving normal vascular structures.

Stent-Assisted Embolization: In select cases with high-flow fistulas, a stent was deployed to provide structural support and prevent coil migration.

Balloon-Assisted Occlusion: Balloon catheters were used in conjunction with coil embolization to achieve controlled occlusion of the fistula.

Glue Embolization: Liquid embolic agents, such as Onyx-18, were used in cases where residual shunting was present despite coil embolization.

The transarterial approach was the preferred route for embolization, with the femoral artery serving as the primary access site. In cases with challenging arterial access, a transvenous approach through the superior ophthalmic vein or inferior petrosal sinus was used.

Patients were closely monitored in the post-procedural period for neurological status, ocular symptoms, and potential complications. Follow-up DSA was performed in all cases to assess the durability of embolization and detect any residual or recurrent shunting. Patients with persistent visual deficits or residual fistula flow were scheduled for additional interventions as needed.

A 38-year-old male presented with mild edema in the left eyelid, along with slight exophthalmos, mild ptosis, and mild conjunctival congestion on physical examination. No abnormalities were observed in ocular movements, and no scleral icterus was present. Lens opacities were noted. The left eye was blind, while the right eye exhibited normal vision. The left pupil had a diameter of approximately 4 mm, with an absent light reflex. The right pupil had a diameter of about 3 mm, with a normal light reflex. A blowing sound synchronous with the pulse was detected upon auscultation of the left eye. DSA performed on 19 June 2018, revealed a left ICA cavernous sinus fistula, associated with significant venous congestion in the affected eye. However, the precise location of the fistula could not be definitively determined based on the imaging findings. Figures 1A, B shows preoperative left ICA anteroposterior angiography.

A first surgery was performed on 22 June 2018, under general anesthesia. The Seldinger technique was used to puncture the right femoral artery, and an 8F sheath was successfully inserted. A 6F catheter was advanced to perform left ICA angiography, confirming the presence of a cavernous sinus arteriovenous (AV) fistula. The 6F Envoy guiding catheter was advanced to the cervical segment of the left ICA, and a microcatheter was employed to precisely identify the fistula’s location. To occlude the fistula, a series of embolization coils (14 × 30, 12 × 30, 10 × 30, 9 × 30) were deployed.

During the filling process, while adjusting the 5 × 10 coil, it unwound, with portions prolapsing through the fistula opening into the ICA. To mitigate this, a balloon was temporarily inflated to compress the distal end of the fistula. Attempts to reposition the prolapsed coils were unsuccessful, as they could not be reinserted into the fistula opening. Given the high risk of additional coil migration into the ICA with continued embolization, a stent was deployed to safeguard the ICA near the fistula. Following the deployment of the stent’s distal end, tirofiban was administered to prevent thrombosis. Subsequently, a 5 × 10 coil was introduced to further occlude the fistula. Upon full stent deployment, the coil was detached, and angiographic assessment confirmed that the prolapsed segment adhered securely to the vessel wall. Post-embolization angiography demonstrated partial occlusion of the fistula with preserved distal ICA perfusion. Considering the challenges of further embolization via the transarterial route, the procedure was concluded. (Figures 1C, D).

A second surgery was performed on 2 August 2018. During this procedure, angiography revealed coil embolization at the fistula site, but the fistula persisted with some retrograde flow to the eye veins. A second intervention via left external jugular vein access was attempted but was unsuccessful. The eye venous approach was then used, allowing successful access and embolization of the remaining fistula (Figures 1E–G). Post-operative evaluation on 14 August 2018, showed that the patient was awake with stable vital signs, left-eye blindness, no significant headache, and normal right-eye vision.

A 31-year-old female presented with a craniocerebral trauma, including brain contusion, subarachnoid hemorrhage, and a right temporal bone fracture. Clinically, she exhibited right eye conjunctival congestion and slight proptosis. The patient also reported mild right ear tinnitus for the past 2 months and right eye ball congestion for the past 2 days. Additionally, hyperuricemia was noted in her medical history. A surgical intervention was performed under general anesthesia. Access to the right femoral artery was obtained via the Seldinger technique, and a 5F catheter was advanced for angiographic imaging. Angiography confirmed the presence of a right ICA cavernous sinus fistula, with arterial flow shunting into the ophthalmic veins and contralateral cavernous sinus (Figures 2A, B). Fistula embolization was attempted using a combination of coils and embolic glue; however, the anatomical complexity of the fistula hindered complete occlusion. Multiple embolization attempts were made, resulting in partial occlusion of the fistula (Figures 2C, D). Post-operatively, the patient experienced resolution of the right ear vascular murmur. Although some residual headaches persisted, the patient’s overall condition improved, and she was closely monitored for ongoing recovery.

An 18-year-old male presented with severe trauma following a high-impact injury. Upon arrival, he was in a coma with a Glasgow Coma Scale (GCS) score of 5, indicating severely impaired neurological status. Clinical examination revealed bilateral fixed pupils, and imaging studies suggested the presence of a significant open traumatic brain injury, which included brain herniation, multiple contusions, and a subdural hematoma. In addition to the brain injury, the patient had other associated trauma-related injuries, including pulmonary contusions, rib fractures, and a traumatic eye rupture. A detailed angiographic evaluation under general anesthesia revealed the presence of bilateral internal carotid artery (ICA) cavernous sinus fistulas (CSFs), with significant arterial-to-venous shunting (Figures 3A–D). These vascular injuries contributed to an abnormal hemodynamic state, which compounded the patient’s neurological deterioration.

To address the cavernous sinus fistulas, the interventional radiology team employed a combination of coils and embolic agents to occlude the fistulas, effectively halting the abnormal shunting between the internal carotid arteries and the cavernous sinuses. The procedure was successful, and post-embolization angiography demonstrated a satisfactory outcome (Figures 3E, F), with significant reduction in shunting. The patient was monitored in the intensive care unit, with ongoing management for his multiple injuries. Although he remained in a coma for some time after the procedure, gradual neurological improvement was observed. The timely diagnosis and intervention for the bilateral ICA cavernous sinus fistulas played a critical role in stabilizing his condition and contributing to his recovery.

A 64-year-old female presented with symptoms following a traumatic injury, including sudden vision loss in her left eye and signs of ocular and neurological distress resulting in a left internal carotid artery (ICA) cavernous sinus fistula. On examination, she had left eye blindness, and further investigation revealed a traumatic fistula at the left ICA cavernous sinus region, which contributed to significant clinical findings, including left eye blindness. The patient’s condition required immediate intervention to address the fistula and prevent further neurological complications. Angiographic imaging confirmed the presence of the traumatic fistula (Figures 4A–C), revealing abnormal communication between the left ICA and the cavernous sinus, which led to disturbed blood flow and ocular symptoms. A microcatheter was carefully navigated into the affected region to treat the fistula, and a combination of coil embolization and glue injection was employed to occlude the fistula. This procedure successfully achieved a satisfactory closure of the abnormal connection between the artery and the sinus, thereby stabilizing the patient’s hemodynamics and preventing further progression of the fistula (Figures 4D, E). Post-operative follow-up revealed that the patient’s left eye blindness persisted, though there was a slight improvement in her vision impairment. While the overall ocular condition did not fully recover, the intervention successfully addressed the vascular abnormality, preventing further neurological deterioration and stabilizing her condition.

A 64-year-old female presented with acute onset of dizziness and headache lasting for 23 h. Initial clinical assessment in the emergency department suggested a diagnosis of intracranial hemorrhage. Further diagnostic workup revealed multiple comorbidities, including a ruptured aneurysm at the bifurcation of the ICA with concomitant subarachnoid hemorrhage, left ICA cavernous sinus fistula, hydrocephalus, intracranial infection, Pseudomonas aeruginosa pneumonia, hypertension grade 3, coronavirus infection, urinary tract infection, hyperammonemia, hypoalbuminemia, and hypokalemia. On admission, the patient was lethargic, exhibiting a reduced level of consciousness but responsive to verbal stimuli. Speech was slurred, and the patient was able to answer questions appropriately, reporting dizziness, headache, blurred vision in the right eye, nausea, and generalized weakness. Neurological examination revealed no signs of limb twitching, opisthotonus, or trismus, and respiratory examination showed no signs of dyspnea or cyanosis. The patient was afebrile, with no signs of incontinence or other autonomic dysfunction.

In the surgical setting, the patient was positioned supine on the operating table, and general anesthesia was successfully induced. After routine aseptic preparation, a modified Seldinger technique was used to puncture the right femoral artery and a 6F vascular sheath was inserted. Systemic anticoagulation was achieved with heparin, and a 6F pig-tail catheter was used to perform an aortic arch angiogram, which revealed a type I aortic arch. A 5F single-curve diagnostic catheter was advanced into the bilateral internal carotid arteries, vertebral arteries, and subclavian arteries. A 3D rotational angiogram of the left ICA demonstrated a wide-necked, saccular aneurysm at the bifurcation of the left ICA, measuring approximately 9.17 mm × 4.27 mm x 5.74 mm. The aneurysm was predominantly supplied by the left ICA, and no significant abnormalities were noted in the remaining vascular structures. Based on these findings, stent-assisted embolization was planned.

An 8F vascular sheath was exchanged, and an 8F guiding catheter was advanced to the distal cervical segment of the left ICA under the guidance of a microguidewire. An intermediate catheter was advanced to the cavernous sinus segment of the left ICA. Using the roadmapping technique, a Headway-21 microcatheter was navigated into the M1 segment of the middle cerebral artery, followed by placement of a Headway-17 microcatheter into the aneurysm. A 7 mm × 22 cm coil was deployed into the aneurysm, and the coil was released. Following intravenous administration of Verapamil, an LVIS 3.5 mm × 20 mm partially deployed stent was placed to provide a scaffolding effect. Another 7 mm × 22 cm coil was deployed, forming a basket-like structure within the aneurysm, followed by the deployment of additional coils (5 mm × 15 cm, 4 mm × 10 cm, 4 mm × 10 cm, 2 mm × 8 cm, 2 mm × 6 cm, 1.5 mm × 4 cm) to ensure complete embolization. Post-embolization angiography confirmed dense embolization of the aneurysm, with no residual flow within the aneurysm sac.

Post-procedural angiography using a lateral view of the left ICA confirmed the presence of the cavernous sinus fistula, with the fistula orifice located in the cavernous sinus segment of the left ICA (Figure 5). The fistula was found to drain into the superior and inferior ophthalmic veins, the pterygoid plexus, and the superior and inferior petrosal sinuses. No significant abnormalities were noted in the remaining vascular territories.

A 6F vascular sheath was inserted into the left femoral vein, and the Headway-17 microcatheter was advanced under the guidance of a Traxcess microguidewire through the fistula into the cavernous sinus. A balloon catheter was then positioned in the cavernous sinus orifice of the right ICA. Coils (10 mm × 30 cm, 8 mm × 30 cm, 7 mm × 30 cm, 7 mm × 30 cm, 6 mm × 20 cm, 6 mm × 20 cm) were deployed to embolize the fistula. Following balloon deflation, additional coils (5 mm × 15 cm, 5 mm × 15 cm) were deployed, and intermittent imaging was performed to assess the degree of occlusion. Angiographic results showed a significant reduction in the fistula flow. Additional coils (9 mm × 24 cm, 6 mm × 20 cm, 6 mm × 18 cm, 5 mm × 12 cm) were deployed, followed by the injection of embolic glue under intermittent fluoroscopic guidance. This resulted in further reduction in cavernous sinus opacification, and final angiography showed reduced fistula flow with preservation of distal arterial patency.

A 46-year-old female presented with right eye redness, pain, and a foreign body sensation for more than 10 days. The outpatient diagnosis considered an inflammatory orbital pseudotumor of the right eye. The final diagnosis included: 1. Left ICA cavernous sinus fistula, 2. Paralytic strabismus in both eyes, 3. Entropion and trichiasis in the right eye, and 4. Keratitis in the right eye. Upon admission, the patient experienced right eye redness, pain, blurred vision, and diplopia but no dizziness, headaches, nausea, or vomiting. Her appetite was acceptable, sleep was disturbed, and her bowel and urinary functions were normal. On examination, her visual acuity was 0.15 in the right eye and 0.3 in the left eye. Intraocular pressure was 27.0 mmHg in the right eye and 19.5 mmHg in the left eye. Both eyes showed limited outward gaze. In primary gaze, the right eye had an internal deviation of approximately 30°, with the lower eyelid showing entropion, where the eyelashes were directed toward the cornea, causing friction and conjunctival hyperemia. A grayish-white infiltration was noted in the inferior cornea. The left cornea appeared clear, and both eyes were negative for keratic precipitates. The anterior chamber depth was normal, the aqueous humor was clear, the iris patterns were distinct, and the pupils were round at 3 mm with a normal light reflex. Mild lens opacities were noted, and fundoscopy was not possible.

For the diagnostic angiography, the patient was placed in the supine position, and after routine disinfection and draping, 2% lidocaine was applied for local anesthesia. The modified Seldinger technique was used to puncture the left femoral artery and place a 5F vascular sheath. After systemic heparinization, a 5F pig-tail catheter was used for aortic arch angiography, which showed a type I aortic arch. A 5F curved catheter was positioned in the bilateral common carotid arteries, internal carotid arteries, external carotid arteries, subclavian arteries, and vertebral arteries for angiography, with imaging of the cervical and intracranial segments. A three-dimensional rotational angiogram of the left ICA revealed a cavernous sinus fistula with the fistula site located on the inferior wall of the cavernous sinus segment, draining into the superior petrosal sinus, superior ophthalmic vein, inferior ophthalmic vein, intercavernous sinus, and pterygoid plexus veins. The anterior communicating artery and left posterior communicating artery were patent, with good collateral circulation. The procedure was completed successfully, and after heparin neutralization with protamine sulfate, the femoral sheath was removed. Hemostasis was achieved by manual compression for 15 min, and sterile dressings were applied. No bleeding was noted at the puncture site, and dorsalis pedis pulses were intact.

For the interventional procedure, the patient was placed supine and underwent general anesthesia with endotracheal intubation. After standard disinfection and draping, a modified Seldinger technique was used to puncture the right femoral artery and place a 6F vascular sheath. The patient was systemically heparinized. A 6F Envoy catheter was placed in the cervical segment of the left internal carotid artery with the assistance of a Glidewire. A Headway-17 microcatheter was advanced through the fistula into the origin of the superior ophthalmic vein, and another Headway-17 microcatheter was navigated through the fistula into the cavernous sinus. A Complex 18 coil (20 mm × 50 cm) was deployed via the superior ophthalmic vein microcatheter. However, during the advancement, there was insufficient support from the guiding catheter, and vessel spasm was noted, possibly due to the tortuosity of the left ICA. An 8F vascular sheath was then placed, and an 8F guiding catheter was used to guide a SilverSnake intermediate catheter to the petrous segment, with the Glidewire assisting in navigation. Two Headway-17 microcatheters were again advanced through the fistula into the cavernous sinus and superior ophthalmic vein. Multiple coils were deployed, including a Complex 18 20 mm × 50 cm, Helical 18 Regular 18 mm × 30 cm, Helical 18 Regular 18 mm × 30 cm, Helical 18 Regular 18 mm × 30 cm, Helical 18 Regular 14 mm × 30 cm, Helical 18 Regular 10 mm × 30 cm, and Helical 18 Regular 6 mm × 20 cm, which successfully occluded the cavernous sinus fistula. After the superior ophthalmic vein microcatheter was withdrawn, a small portion of the fistula still drained into the superior petrosal sinus. A DMSO solution (0.3 mL) was injected through the microcatheter, followed by EVAL-I glue. Sequential angiographic imaging showed a progressive reduction in cavernous sinus filling, and after 0.5 mL of glue was injected, the cavernous sinus fistula was completely occluded. Final angiography confirmed that distal blood flow was preserved (Figure 6). The procedure was successful, and protamine sulfate was used to neutralize heparin. The right femoral sheath was removed, and manual compression was applied for 15 min. The puncture site showed no bleeding, and dorsalis pedis pulses were intact. At discharge, the patient’s condition had improved, with clear vision and resolution of the pain and redness. She no longer experienced double vision, dizziness, headaches, nausea, or vomiting. Her appetite and sleep had normalized, and her bowel and urinary functions were stable. Her pupils were round, with a diameter of about 3 mm and a normal light reflex. The right eye exhibited limited abduction.