Carotid and transcranial color-coded duplex sonography in different types of carotid-cavernous fistula

Patients with carotid-cavernous fistula (CCF) may undergo direct or indirect shunting. Ultrasonography has value that is complementary to angiography in the assessment and follow-up of these patients. The aim of this study was to characterize findings provided by carotid duplex sonography (CDS) and transcranial color-coded duplex sonography (TCCD) in patients with different types of CCF.

CDS and TCCD were independently performed by technologists and neurologists. Digital subtraction or MR angiography was interpreted by a neuroradiologist. Ultrasonographic studies were categorized into 4 types: I, direct shunting only; II, direct shunting with a carotid aneurysm; III, indirect shunting only; and IV, mixed (direct and indirect) shunting. In addition to carotid and intracranial flow velocities, volume, and pulsatility, other direct and indirect ultrasound signs of shunting were evaluated. The direct sign of CCF was a mosaic flash detected by TCCD. Alteration of hemodynamic parameters on CDS and demonstration of draining veins with the use of TCCD were considered indirect signs.

Fifteen patients (8 men, 7 women) were included in the study. According to angiographic results, patients in ultrasonographic classification types I (n=7) and II (n=3) corresponded to type A of Barrow's classification. Patients with type III (n=8) were Barrow's type C. Type IV (n=1) had a combination of Barrow's types A and C. On ultrasound, both direct and indirect signs were seen in types I, II, and IV CCF. The presence of a 2-colored oval mass divided by a zone of separation without turbulence differentiated type I from type II CCF. All patients with type III CCF had indirect signs, and only 1 patient had direct signs on TCCD. Abnormal TCCD findings were most commonly seen through the transorbital window (100%), followed by the transtemporal window (63%) and transforaminal window (40%).

If only indirect ultrasonographic signs of CCF are present, TCCD can be used to predict an indirect CCF type on the basis of the origin of the fistula. With direct communication between carotid artery and cavernous sinus, both direct and indirect ultrasonographic signs can be found. The combination of CDS/TCCD may provide a noninvasive and reliable way to classify patients with CCF.