Clinico-Radiological Presentation and Management of Carotid-Cavernous Fistulae: Real-Time Institutional Experience From Pakistan

Background: Carotid-cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus. This communication can be either high-flow or low-flow. Depending on the distinct anatomy of the shunt, it has effects on the various neurovascular structures that lie within the cavernous sinus. Objective: To evaluate the immediate outcomes of CCF patients undergoing surgical and endovascular management. Methodology: This is a retrospective observational study conducted at the Departments of Neuroendovascular Surgery and Neurosurgery at Punjab Institute of Neurosciences, Lahore. Consecutive patients diagnosed with CCF, who underwent diagnostic evaluation or treatment at the institution between January 2023 and December 2025, were included. Descriptive statistics were applied to analyze characteristics and outcomes. Results: Of the total 10 patients, the most common clinical presentation was proptosis (90%; n=9), followed by chemosis (40%; n=4), ophthalmoplegia (30%; n=3), and cranial nerve palsy (10%; n=1). The majority of these cases were high flow (80%; n=8), categorized as being Barrow A. Arterial feeders originated exclusively from the internal carotid artery (ICA) in 60% (n=6) of cases, while 10% (n=1) were from the external carotid artery (ECA). Anterior and posterior drainage of CCF was mediated by the superior ophthalmic veins (SOV) (40%; n=4) and inferior petrosal veins (IPV) (20%; n=2), respectively. The majority of patients in our case series underwent stent (PK Papyrus, Biotronik SE & Co. KG, Berlin, Germany) placement, i.e., 70% (n=7), followed by ICA ligation in 20% of cases (n=2). Postoperative imaging revealed a fistulous leak in 60% (n=6), complete obliteration in 10%, and mild flow in 1% (n=1). Clinical outcomes improved in 90% (n=9), and no post-procedural hemorrhage, infarction, or cranial nerve deficit was reported. Conclusions: Most of the patients had neuro-ophthalmic manifestations. Direct-type CCFs were the common type in our small case series, affecting the male gender predominantly, and most cases were post-traumatic. The endovascular management of CCF using covered stent deployment (PK Papyrus) yields reasonable radiological obliteration of the fistula, improved visual outcomes, and minimal intraoperative and immediate postoperative complications.