Endovascular treatment of direct carotid cavernous fistula resulting from rupture of intracavernous carotid aneurysm: A case report

BACKGROUND Direct carotid cavernous fistulas(CCFs)are typically the result of a severe traumatic brain injury.High-flow arteriovenous shunts secondary to rupture of an intracavernous aneurysm,resulting in direct CCFs,are rare.The use of a pipeline embolization device in conjunction with coils and Onyx glue for treatment of direct high-flow CCF resulting from ruptured cavernous carotid artery aneurysm in a clinical setting is not well documented.CASE SUMMARY A 58-year-old woman presented to our department with symptoms of blepharoptosis and intracranial bruits for 1 wk.During physical examination,there was right eye exophthalmos and ocular motor palsy.The rest of the neurological examination was clear.Notably,the patient had no history of head injury.The patient was treated with a pipeline embolization device in the ipsilateral internal carotid artery across the fistula.Coils and Onyx were placed through the femoral venous route,followed by placement of the pipeline embolization device with assistance from a balloon-coiling technique.No intraoperative or perioperative complications occurred.Preoperative symptoms of bulbar hyperemia and bruits subsided immediately after the operation.CONCLUSION Pipeline embolization device in conjunction with coiling and Onyx may be a safe and effective approach for direct CCFs.

Endovascular treatment of carotid cavernous sinus fistula: A systematic review

Carotid cavernous sinus fistulas are abnormal communications between the carotid system and the cavernous sinus. Several classification schemes have described carotid cavernous sinus fistulas according to etiology, hemodynamic features, or the angiographic arterial architecture. Increased pressure within the cavernous sinus appears to be the main factor in pathophysiology. The clinical features are related to size, exact location, and duration of the fistula, adequacy and route of venous drainage and the presence of arterial/venous collaterals. Noninvasive imaging (computed tomography, magnetic resonance, computed tomography angiography, magnetic resonance angiography, Doppler) is often used in the initial workup of a possible carotid cavernous sinus fistulas. Cerebral angiography is the gold standard for the definitive diagnosis, classification, and planning of treatment for these lesions. The endovascular approach has evolved as the mainstay therapy for definitive treatment in situations including clinical emergencies. Conservative treatment, surgery and radiosurgery constitute other management options for these lesions.

Endovascular procedure-related spontaneous closure of traumatic carotid cavernous fistula: case report

Objective BACKGROUND Spontaneous closure of direct traumatic carotid cavernous fistulas (TCCFs) is rare. A few cases have been reported in literature to be related to diagnostic cerebral angiography and orbital venography. Several mechanisms have been postulated, including irritation of the vessels from contrast media, compression of the carotid artery and reduced blood pressure from general anesthesia. In our own series of about 400 patients at Ramathibodi Hospital, the incidence is approximately 1.75%.CASE PRESENTATION We present a case, which spontaneous closure occurred during attempted endovascular embolization. A 45-year-old woman with left TCCF was referred to our hospital for endovascular treatment. Cerebral angiogram revealed a small-hole fistula at the posterosuperior wall of C2-3 segment of the LICA. Transarterial balloon failed due to the small size of the fistula and acute retroangulation of the balloon attached microcatheter. Transarterial GDC coil placement into the first venous pouch was then attempted for two times, but was unsuccessful. During repositioning of the microcatheter for a third attempt, spontaneous closure of the fistula was observed and confirmed by control angiogram. CONCLUSION Spontaneous closure of direct traumatic carotid cavernous fistulas may occur during endovascular procedures, which can be caused by dissection of the venous pouch by the microcatheter or coils during manipulation, irritation of the vascular walls from the contrast media and decreased blood pressure from general anesthesia.

Color Doppler Imaging in the Diagnosis and Follow-up of Carotid Cavernous Sinus Fistulas

This report describes color doppler imaging (CDI) in theevaluation and follow-up of nine patients with carotid cavernous sinusfistulas.The orbits and carotid arteries were examined with CDI.In allcases,the diagnosis was confirmed by angiography.CDI clearlydemonstrated the dilated superior ophthalmic veins (SOVs) with retrogradeflow and low resistance arterial doppler waveform in all nine patients (10eyes).After the study of quantitative hemodynamics,we found that directcarotid cavernous sinus fistulas s...

Endovascular management of carotid-cavernous fistulas

Objective To investigate endovascular treatment of traumatic direct carotid-cavernous fistulas (CCF) and their complications such as pseudoaneurysms. Methods: Over a five-year period, 22 patients with traumatic direct CCFs were treated endovascularly in our institution. Thirteen patients were treated once with the result of CCF occluded, 8 twice and 1 three times. Treatment modalities included balloon occlusion of the CCF, sacrifice of the ipsilateral internal carotid artery with detachable balloon, coil embolization of the cavernous sinus and secondary pseudoaneurysms, and covered-stent management of the pseudoaneurysms. Results All the direct CCFs were successfully managed endovascularly. Four patients developed a pseudoaneurysm after the occlusion of the CCF with an incidence of pseudoaneurysm formation of 18.2% (4/22). A total number of 8 patients experienced permanent occlusion of the ICA with a rate of ICA occlusion reaching 36.4% (8/22). Followed up through telephone consultation from 6 months to 5 years, all did well with no recurrence of CCF symptoms and signs. Conclusion Traumatic direct CCFs can be successfully managed with endovascular means. The pseudoaneurysms secondary to the occlusion of the CCFs can be occluded with stent-assisted coiling and implantation of covered stents.

Transvenous Embolization of Carotid Cavernous Fistula by Sequential Occlusion of the Cavernous Sinus

Objective Introduction When we perform transvenous embolization of carotid cavernous fistula, we selectively occluded the venous outflow to the retrograde cortical venous drainage and retrograde ophthalmic venous drainage as the initial steps before the rest of the cavernous sinus. The rationale is to prevent re-diversion of flow into the ophthalmic veins and cortical veins in a subtotally occluded carotid cavernous fistula.Method From 1997 to 2004, a total of 46 patients with carotid cavernous fistula were treated by transvenous embolization using the proposed selective occlusion strategy. There were 6 direct and 40 dural cartoid cavernous fistulae. The embolic agents were Guglielmi detachable coils and fibered platinum coils. Transvenous embolization routes included inferior petrosal sinus (IPS) alone (32 patients), IPS and intercavernous sinus (9 patients), and superior ophthalmic vein (5 patients).Result The follow-up period ranged from 4 months to 7 years. One patient developed retinal hemorrhage due to ophthalic vein thrombosis one week after the embolization procedure. Two patients had transient ophthalmoplegia and 2 patients had symptomatic recurrence of the carotid cavernous fistula during the follow-up. Clinical cure was achieved in 44 patients (96%).Conclusion The sequential occlusion strategy offers a safe and effective method in the transvenous embolization of carotid cavernous fistula.

Endovascular treatment of traumatic direct carotid cavernous fistulas with n-Butyl-2-Cyanoacrylate

Objective To explore the method and safety of endovascular treatment of traumatic direct carotid cavernous fistulas with n-Butyl-2-Cyanoacrylate. Method A total of 11 patients with traumatic direct carotid cavernous fistulas treated by endovascular embolization with n-Butyl-2-Cyanoacrylate. (n-BCA) were retrospectively analyzed,including the

Management of traumatic carotid-cavernous fistula

Sixty-eight patients with traumatic carotid-cavemous fistula (TCCF) were treated by intravascular embolization. All patients were cured and 94.1% of internal carotid arteries were preserved. Proptosis, bruit and chemosis disappeared following embolization. The diagnosis and management of TCCF are also evaluated.

Management of Carotid Carvenous Fistula in Ghana;Challenges and Opportunities

Carotid-cavernous fistula is an abnormal communication between the carotid artery and the cavernous sinus. The fistula is classified based on its etiology, haemodynamic and anatomical configuration. The most common type is the direct high flow fistula resulting from trauma. Indirect fistula which is less common results from underlying conditions such as hypertension, collagen vascular diseases, pregnancy amongst others. It is in regards with this uncommon occurrence of indirect fistula that we report a case of forty years old woman who presented with a left protruding eyeball and headache a month after delivery and was diagnosed with spontaneous type D indirect carotid cavernous fistula with rapidly progressing symptoms. She was referred abroad for interventional radiological services due to unavailability of such services in our facility and country.

外伤性颈内动脉海绵窦瘘(TCCF)介入治疗前后经颅多普勒超声检测的临床意义

目的 检测外伤性颈内动脉海绵窦瘘 (Traum atic carotid cavernous fistula,TCCF)介入治疗前后脑动脉血流动力学变化。方法 对 16例 TCCF患者采用 TCD检测颅底主要动脉的血流速度、脉动指数、频谱形态、声频变化。结果 治疗前患侧动脉出现快流速 ,低脉动指数、紊乱频谱血流信号伴明显杂音 ,尤以眼上静脉的异常为主。栓塞后异常血流信号消失。结论 TCD是协助诊断 CCF的无创伤方法。是监测介入治疗后 CCF是否完全栓塞的重要手段 ,压颈试验对了解侧枝循环非常重要。

颈动脉海绵状瘘的眼科表现及研究进展

颈动脉海绵窦瘘通常以眼部症状为首发临床表现,由于其表型多变,患者常被误诊为其他眼部疾病,极易漏诊误诊,导致治疗延误,因此我们通过对颈动脉海绵窦瘘进行文献综述,有助于了解颈动脉海绵窦瘘的眼部特征、分类诊断、可能的治疗模式和预期结果。

眼眶病1例

20岁男性患者,因交通事故后右眼眶骨折入院。患者门诊首诊时无颈动脉海绵窦瘘相关症状及体征,伤后2个月检查发现右眼眼压升高,伴有结膜血管扩张。脑磁共振血管成像(MRA)证明为右侧创伤性颈动脉海绵窦瘘,动脉造影证实了这一点,患者对栓塞治疗反应良好。讨论体会:该病例的临床意义在于临床诊疗过程中必须重视基本的体格检查,创伤后高眼压需系统分析其可能的因素,并且在外伤后数月,也应该考虑创伤性颈动脉海绵窦瘘存在的可能性。

Diagnosis and endovascular treatment of spontaneous direct carotid-cavernous fistula

Background Spontaneous direct carotid-cavernous fistula （CCF） is relatively rare and few reports have been found in the literature. The aim of this paper was to report the clinical characteristics, imaging findings and curative effect of endovascular treatment for patients with spontaneous direct CCF. Methods We retrospectively analyzed the clinical data of nine patients with spontaneous direct CCF admitted between May 2003 and November 2007 and the outcomes.of endovascular treatment. Sudden neuro-ophthalmological symptoms were the most common clinical presentation at diagnosis （n=8）. No patients had a history of head trauma. Cerebral digital subtraction angiography （DSA） was performed on all cases under local anesthesia and seven cases received endovascular treatment. Results In eight patients, internal carotid angiograms recorded during the early arterial phase revealed aneurysms located in the cavernous sinuses, and in one patient, a dilated internal carotid artery （ICA） was seen. Among the nine cases, seven received endovascular treatment via a transarterial approach and complete occlusion of the fistula was obtained with no technique-related complications, one died suddenly before treatment and one gave up treatment. A detachable balloon was used as the embolic material in two cases, a detachable balloon and detachable coil as the embolic material in two cases, balloon-assisted coil embolization in two cases and covered stents were successfully placed in the parent vessel to exclude the aneurysm and fistula from circulation in one case. During a follow-up period of 3-48 months, all treated patients remained asymptomatic except for one patient who suffered from ipsilateral decreased vision. Conclusions Most spontaneous direct CCF may be caused by a ruptured intracavernous aneurysm with direct shunting into the cavernous sinus. Endovascular treatment seems to be a safe and effective method for treating spontaneous direct CCF.

Transvenous treatment of a complex cavernous sinus dural arteriovenous fistula secondary to balloon embolization of a traumatic carotid-cavernous fistula

Although recurrent traumatic carotid-cavernous fistula （CCF） and its treatment have beenreported sporadically,^1 a complex cavernous sinus dural arteriovenous fistula （DAVF） secondary to balloon embolization of a direct traumatic CCF is rare. In 2005, we treated such a case via transvenous approach using coils and N-buty-2- cyanoacrylate （NBCA）. The causes of recurrent cavernous sinus DAVF and its endovascular approach are discussed.

粉碎性颅底骨折后CCF合并脑脊液漏的治疗策略

目的探讨粉碎性颅底骨折后颈内动脉-海绵窦瘘(CCF)合并脑脊液漏的治疗策略。方法对9例粉碎性颅底骨折后出现CCF伴明显脑脊液漏的患者应用血管内介入、腰大池穿刺负压持续引流和后期颅骨整复等方法进行综合治疗。结果共治愈8例,1例由于颅脑损伤严重合并心肺衰竭死亡。平均住院时间53 d。颅内严重感染1例,经负压持续引流及抗生素等治疗后痊愈。结论对于粉碎性颅底骨折后CCF合并脑脊液漏的综合治疗,应优先处理血管性损伤,因为这个问题往往最危急,并且它的存在会严重妨碍其他问题的解决;脑脊液漏早期即行保守治疗,最危急的问题解决后行腰大池置管负压持续引流,治愈率、安全性高;后期颅骨整复造成的二次损伤处理更从容,风险更小。

Prognostic analysis and complications of traumatic carotid cavernous fistulas after treatment with detachable balloon and/or coil embolization

Objective: To explore the causes of the formation of traumatic carotid-cavernous fistulas and the therapeutic effect of detachable balloon and/or coil embolization and the prevention of its complications. Methods: From October, 1992 to March, 2002, 17 patients with traumatic carotid-cavernous fistulas were treated with detachable balloon and/or coil embolization in our hospital. The clinical data and imaging features of CT, MR and selective angiogram of these patients were analyzed. Results: One week after treatment with embolization, the clinical symptoms of the 17 patients were remitted, and optic cacophony, nystagmus, exophthalmos and dropsy of conjunctiva disappeared. Two patients manifested surgical complications, one patient died. Sixteen patients survived. They were all followed up for more than 2 years, which showed one patient had handicap in movement, and in one patient the signs and symptoms of traumatic carotid-cavernous fistulas reoccurred 2 months after treatment. Conclusions: The detachable balloon and/or coil embolization is safe and reliable. It is a good method to treat traumatic carotid-cavernous fistulas.

Multimodal endovascular treatment for traumatic carotid- cavernous fistula

在场的 ObjectiveTo 我们在在我们的医院里与在 2004 年 1 月和 2012 年 10 月之间的 TCCF 由 28 个病人的多模式的 endovascular treatment.MethodsThe 管理对待创伤的颈动脉多孔的管(TCCF ) 的经验回顾地被分析。根据成像 charateristics， 24 个盒子被分成类型我， 3 类型 II 和 1 类型 III。完全， 30 endovascular 治疗被执行：类型我 TCCF 经由 transvenous 被涂抹途径(7/25 ) ，或由可拆卸的汽球吸藏的包括 6 的 transarterial 途径(18/25 ) ， 6 由 microcoil embolization， 3 由 Hyperglide 帮助汽球的卷 embolization 并且 3 由可拆卸的汽球和卷 embolization 的联合。二个病人与内部颈动脉动脉(集成通信适配器) 的闭合被对待。类型 II TCCF 与 transvenous embolotherapy (2/3 ) 或颈动脉动脉压缩治疗(1/3 ) 被对待。类型 III 病人经历了手术后的 angiography 显示出的可拆卸的汽球 embolization.ResultsImmediate 在 26 种情况中的恢复。一周期性的 TCCF 2 个星期在可拆卸的汽球 embolization 以后被发现，然后由 transarterial 卷重新涂抹。重考在可拆卸的汽球和卷 embolization 的联合以后在 1 病人一月内发现了汽球放气和管开运河，它被第二治疗经由 transvenous 途径治好。立即的 angiography 在 4 个病人揭示了剩余血流动。在他们之中，有在后续的推迟的症状的 2 个病人需要第二治疗， 1 个病人在颈动脉动脉压缩治疗以后恢复了，并且留下的 patient’s 症状消失在在五月的后续的数字减法 angiography 上。CT angiography 在与集成通信适配器的闭合被对待的病人揭示了前面的交流动脉动脉瘤到图象，管的特征和排水的类型的结果的 4 年 later.ConclusionAccording 能最大地愈合病理学的变化，保留 ipsilateral 集成通信适配器明显并且减少长期的复杂并发症。