Artificial embolic occlusion of the terminal internal carotid artery in the treatment of carotid-cavernous fistula. Technical note.

Abstract

HE most radical and effective treatment of carotid-cavernous fistula consists of isolation of the cavernous portion of the internal carotid artery by ligation in the neck after intracranial clipping of its terminal portion. Because of its hazards, however, this procedure is often avoided, and the results are correspondingly poor. This report describes the successful intraluminal occlusion of the terminal internal carotid artery by embolization with a porcelain bead, thus eliminating the need for craniotomy. Case Report A 42-year-old man had been brutally beaten about the head. He was admitted in deep shock in a stuporous condition with severe facial and scalp lacerations, multiple linear fractures, and a severe right parietal depressed fracture. After treatment for shock, the depressed fragment was removed, a large epidural hematoma was evacuated, and the middle meningeal artery occluded close to the foramen spinosum. The dura had not been damaged. The patient made an uneventful recovery. Two months after discharge the patient became aware of a pulsatile bruit over the left eye; in the course of the next 2 weeks this eye protruded severely. There was chemosis and engorgement of conjunctival vessels in both eyes, more marked in the left. The optic discs were normal but the retinal veins were slightly engorged. There was no visual impairment. Intraocular pressure was elevated to 22 mm Hg in the right eye and 24 mm Hg in the left eye. All over the cranium a blowing bruit could be heard, louder over the left eye, and synchronous with the pulse and abolished by carotid compression. Left carotid angiography (Fig. 1 left) dem