Combined direct and indirect traumatic carotid-cavernous fistula (CCF): Case report and review of the literature

Background Within the current Barrow classification system, there are no categorical descriptions or reports in the literature of cavernous carotid fistulas (CCFs) with both a direct component (type A) and separate indirect contribution (type B, C, or D). We report the first definitive case of a combined simultaneous traumatic direct and indirect CCF, and review the literature on the similar existing entity of traumatic indirect CCFs presenting delayed and subsequent to the treatment of traumatic, direct CCFs. Methods We report a case of simultaneous direct type A CCF with a traumatic indirect CCF component and a review of the relevant literature. Results An 18 year-old female presented after a motor vehicle collision. A diagnostic cerebral angiogram confirmed the diagnosis of CCF, with contribution both directly from the ICA and indirectly via branches of the ECA. The direct component of the CCF was first treated in 3 stages via both transarterial and transvenous coil embolization, followed by a final 4th stage of parent vessel sacrifice in order to treat the residual direct component, with transarterial embolization to treat residual indirect CCF activity. Conclusions To our knowledge, this is the first report of a traumatic CCF with simultaneous direct (type A) and indirect via the ECA (type C) contributions.