Carotid-cavernous Fistula Research Articles

Delayed care in carotid-cavernous fistula due to the Covid-19 pandemic

Direct carotid-cavernous fistula is a high-flow communication between the internal carotid artery and the cavernous sinus that requires early transarterial embolization for its resolution. We report a case of a patient with a direct carotid-cavernous fistula who subsequently developed a central retinal vein thrombosis due to a delay in treatment related to the health collapse experienced in the first months of the Covid-19 pandemic in Spain.

Management of neurovascular emergencies with ophthalmic manifestations.

Patients with neurovascular disorders sometimes approach the ophthalmologists with mild ophthalmic clinical features such as conjunctival congestion, slowly progressive proptosis, lateral rectus palsies and at other times with ophthalmic emergencies like sudden increase in proptosis, ophthalmoplegia, diplopia, and ptosis before the onset of neurological manifestations which may be life-threatening if not detected in time. The aim of this article is to focus on ophthalmic manifestations of neurovascular emergencies and role of ophthalmologists in its management. In this communication, to make the ophthalmologist aware of clinical presentations, the imaging modality of choice, diagnostic features, medical and interventional treatments. We have searched PubMed, Web of Science, Google Scholar and reviewed some of the commonly encountered neurovascular emergencies with ocular manifestations such as carotid-cavernous fistula, cerebral venous sinus thrombosis, cerebral artery aneurysms, arterio-venous malformations.

Balloon-Assisted Coil and Liquid Embolizing System Repair of Barrow's Type A Carotico-Cavernous Fistula.

Balloon-Assisted Coil and Liquid Embolizing System Repair of Barrow's Type A Carotico-Cavernous Fistula.

Delayed diagnosis of traumatic internal carotid-cavernous sinus fistula due to multiple trauma

Delayed diagnosis of traumatic internal carotid-cavernous sinus fistula due to multiple trauma

A case of traumatic carotid–cavernous sinus fistula treated by endovascular parent artery occlusion after extracranial to intracranial low flow bypass

A case of traumatic carotid–cavernous sinus fistula treated by endovascular parent artery occlusion after extracranial to intracranial low flow bypass

Transvenous Approaches to Embolization of Dural Arteriovenous Fistulae of the Cavernous Sinus.

Dural arteriovenous fistulae of the cavernous sinus (CS) (previously often referred to indirect carotid cavernous fistulas) are rare vascular shunts involving meningeal branches and osseous branches of the external or internal carotid arteries and the CS. They typically present with ocular symptoms including pain, conjunctival injection, and proptosis. Left untreated there may be a risk of vision loss, and fistulas with cortical venous reflux through either the deep or superficial venous system may cause intracranial venous congestion or hemorrhage. Endovascular embolization is the standard treatment, and while transarterial routes may appear possible, transarterial embolization has considerable risks of ischemic complications. Conversely, transvenous routes achieve a high rate of fistula occlusion with a low risk of peri-procedural morbidity. Procedural success depends on identification of the venous outflows from the fistula and localization of the fistulous point, to select the best route of access to the CS, including the inferior petrosal sinus (IPS), intercavernous sinus, or superior ophthalmic vein, among others. Even if the IPS is not visualized, it may be possible to recanalize it to gain access to the CS. Embolization can be performed with a combination of coils, fibered coils, and liquid embolic agents, focusing on occlusion of the fistulous point or blocking high-risk venous outflow pathways. In this review we will highlight procedural pearls and potential pitfalls and our typical approach to these lesions based on illustrative examples.

A case of traumatic carotid–cavernous fistula 4–month after head injury

A case of traumatic carotid–cavernous fistula 4–month after head injury

The Emergency Coil Embolization of Iatrogenic Injury to Carotid with Supraclinoid Pseudoaneurysm and Carotid Cavernous Fistula: A Case Report

Carotid cavernous fistulae (CCF) are unique communication between the cavernous segment of the internal carotid artery (ICA) and the cavernous sinus. CCF are rare and result from traumatic skull base fractures (0.2-0.8%). CCF resulting from iatrogenic intradural traumatic aneurysms are not common, and they are hard to treat using a surgical approach. This report presents the case of a female patient with iatrogenic CCF, which resulted from proximal ICA injury. The CCF was successfully treated using the endovascular coil embolization. The patient has reported improvement in her vision, one-year follow-up routine has indicated no recurrence with this technique.

Radiation Exposure During Diagnostic and Therapeutic Angiography of Carotid-cavernous Fistula

PurposeThe aim of this study was to determine local diagnostic reference levels (DRLs) during endovascular diagnostics and therapy of carotid-cavernous fistulas (CCF).MethodsIn a retrospective study design, DRLs, achievable dose (AD) and mean values were assessed for all patients with CCF undergoing diagnostic angiography (I) or embolization (II). All procedures were performed with the flat-panel angiography system Allura Xper (Philips Healthcare). Interventional procedures were differentiated according to the type of CCF and the type of procedure.ResultsIn total, 86 neurointerventional procedures of 48 patients with CCF were executed between February 2010 and July 2021. The following DRLs, AD and mean values could be determined: (I) DRL 215 Gy ∙ cm2, AD 169 Gy ∙ cm2, mean 165 Gy ∙ cm2; (II) DRL 350 Gy ∙ cm2, AD 226 Gy ∙ cm2, mean 266 Gy ∙ cm2. Dose levels of embolization were significantly higher compared to diagnostic angiography (p < 0.001). No significant dose difference was observed with respect to the type of fistula or the embolization method.ConclusionThis article reports on diagnostic and therapeutic DRLs in the management of CCF that could serve as a benchmark for the national radiation protection authorities. Differentiation by fistula type or embolization method does not seem to be useful.

Efficacy of the Flow Re-direction Endoluminal Device for cerebral aneurysms and causes of failed deployment

PurposeThe Flow Re-direction Endoluminal Device (FRED) has recently become available for flow diversion in Japan. We have encountered cases that failed to deploy the FRED. In this study, we report our initial experience with the FRED for cerebral aneurysms and clarify the causes of failed FRED deployment.MethodsA retrospective data analysis was performed to identify patients treated with the FRED between June 2020 and March 2021. Follow-up digital subtraction angiography was performed at 3 and 6 months and assessed using the O’Kelly-Marotta (OKM) grading scale.ResultsThirty-nine aneurysms in 36 patients (average age: 54.4 years) were treated with the FRED. The average sizes of the dome and neck were 9.9 mm and 5.2 mm, respectively. In nine patients, additional coiling was performed. In one patient (2.6%), proximal vessel injury caused direct carotid-cavernous fistula during deployment. Ischaemic complications were encountered in one patient (2.6%) with transient symptoms. Angiographic follow-up at 6 months revealed OKM grade C or D in 86.6% of patients. FRED deployment was successful in 35 (92.1%) procedures. In the failure group, the differences between the FRED and the minimum vessel diameter (P = 0.04) and the rate of the parent vessel having an S-shaped curve (P = 0.04) were greater than those in the success group.ConclusionsFlow diversion using the FRED is effective and safe for treating cerebral aneurysms. The use of the FRED for patients with an S-shaped curve in the parent vessel and oversizing of more than 2 mm should be considered carefully.

Bilateral carotid cavernous fistula after trauma: a case report and literature review

BackgroundCarotid cavernous fistula is a rare complication that is typically associated with head trauma and skull base fractures. The traumatic bilateral carotid cavernous fistula are significantly rarer.Case presentationsWe report a case of a 61-year-old man presenting with unilateral exophthalmos, swollen eyelids, conjunctival congestion, and edema etiologically associated with severe trauma. Thereafter, the patient demonstrated symptoms of contralateral oculomotor nerve injury caused by skull base fracture, such as ptosis of eyelid, dilated pupils, and eye movement disorder, and was diagnosed with bilateral carotid cavernous fistula.ConclusionsThe patient recovered after undergoing endovascular embolization of bilateral cavernous sinus fistulas. The patient demonstrated the classic symptoms of an extremely rare condition known as bilateral carotid cavernous fistula, in only one eye. Reporting and analyzing this case will help us elucidate the underlying mechanisms of this disease.

Abstract 1122‐000097: Recurrent Carotid Cavernous Fistula Requiring Complex Repair of Ruptured Cavernous Carotid Aneurysm: A Case Report

Introduction : There are no studies investigating the safety and efficacy of covered stent grafts, particularly the newly developed stents such as the PK Papyrus stent, for endovascular treatment of direct carotid cavernous fistulas (CCFs). Methods : We present a case of a 75‐year‐old female who presented to the hospital with a three‐week history of worsening left eye vision, chemosis, proptosis, and partial third nerve palsy. Patient was found to have left direct Type A CCF secondary to ruptured cavernous segment carotid aneurysm. Results : The CCF was treated with coil embolization and pipeline Shield stent embolization devices with immediate stagnation and improvement of symptoms. Patient had history of an aortic mechanical valve and thus was started on warfarin and ASA. After achieving INR level of 2.5‐3.5, patient started to have recurrent swelling of the left eye associated and decreased visual acuity. Repeated diagnostic cerebral angiogram revealed residual CCF. Onyx liquid embolization and a Surpass Evolve Flow Diverter were attempted to slow the fistulization with no success. Multiple attempts for direct percutaneous superior ophthalmic vein cannulation were also unsuccessful. At this point, two coronary graft‐covered PK Papyrus stents were implanted across the fistula pouch, which resulted in immediate resolution of the CCF with evidence of persistent normal flow within left ophthalmic artery. Patient’s visual acuity and left eye movement improved. Conclusions : This case report highlights the effectiveness and safety of covered stent grafts, particularly more flexible stents such as the PK Papyrus stent, in navigating the carotid vasculature and closing direct CCFs and may be used as a first‐line technique. More large‐scale studies are warranted to investigate the safety and efficacy of using such stent grafts to treat direct CCFs in the setting of antithrombotic agents and anticoagulation.

Endoleak management and postoperative surveillance following endovascular repair of internal carotid artery vascular diseases using Willis covered stent

BackgroundTo report the clinical results and experiences of endoleak management and postoperative surveillance following endovascular repair of internal carotid artery vascular diseases (ICAVDs) using Willis covered stents. METHODS: Seventy-three patients with ICAVD who received Willis covered stent implantation between November 2013 and September 2018 were retrospectively reviewed. The clinical data of endoleak management and postoperative surveillance were analyzed. RESULTS: Seventy-three cases with ICAVD, including 57 aneurysms, 11 carotid-cavernous sinus fistulas (CCF), and 5 surgical injuries, were all successfully installed with covered stents. Total isolation of ICAVDs was achieved in 59 patients (80.8%), and endoleaks were observed in 14 patients (19.2%). Of the 14 patients with endoleaks, 12 had type I endoleaks and 2 had type II; 13 had aneurysms and one had CCF. 10 patients with type I endoleaks received balloon dilatation, and 7 of them underwent a second stent-graft implantation after then. One patient with type II endoleak received embolization of the branch artery, and another one received follow-up observation. Endoleaks resolved in 6 patients and were minimal in 5 patients after balloon dilatation or the second stent implantation. During the follow-up period, minor endoleaks spontaneously resolved in 4 patients and minimal endoleaks were still demonstrated in 4 patients without enlargement of residual lumen and rupture. CONCLUSIONS: Endoleaks are the major complication after endovascular repair of ICAVDs and represent one of the limitations of this procedure. Improving the understanding and management of endoleaks can be beneficial in the clinical setting, including the popularization and application of this technique.

Abstract 1122‐000197: Carotid‐Cavernous Fistula: Does Transcranial Duplex Worth Revisiting?

Introduction : Carotid‐cavernous fistula (CCF) represents a well‐known multifaceted diagnostic challenge starting from clinical presentation till angiography. This case presentation and literature review shed the light on the value of a bedside transcranial duplex (TCD) as a timely and a plausible screening tool. Methods : A case presentation and a brief literature review of CCF diagnosed via transcranial temporal window and made time to angiography shorter than the MRI brain. A review of literature was conducted for the timely diagnostic role of transtemporal TCD compared to transorbital US and an MRI brain. Results : Our case report showed the valuable role of the bedside TCD in diagnosing CCF. There is a limited number of studies which tackled the timely diagnostic role of transtemporal TCD compared to transorbital US and an MRI brain from door to angiography. Conclusions : A large‐sampled randomized controlled trial is needed for evaluating the actual utility of a bed side time and cost‐effective Transtemporal TCD vs other state‐of‐art non‐angiographic diagnostic modalities such as MRI, CT and transorbital US.

Abstract 1122‐000229: Simultaneous Transarterial‐Transvenous Contrast Injection to Reveal Connection Point for Treatment of Carotid Cavernous Fistula

Introduction : Cavernous sinus (CS) via inferior petrosal sinus (IPS) access can present a challenge in the treatment of carotid‐cavernous fistulas (CCF) due to anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection. Methods : A 58‐year‐old male was referred to our academic medical center for three weeks of right eye pain, now complicated by redness, diplopia and blurry vision. Magnetic Resonance Imaging (MRI) brain at the outside hospital revealed hemorrhagic lesion in right parietotemporal region. Computerized tomography‐angiogram (CTA) of the head revealed filling of cavernous sinus during an arterial phase suspicious for CCF. Under general anesthesia, after accessing right common femoral artery, 4 French (F) cook catheter (Cook Medical LLC, Bloomington, IN) was advanced over 0.035 angled glide wire to the proximal right internal carotid artery. Contrast injected through the ICA showed the CS but not the IPS (Fig. 1A). Through the left common femoral vein, access was obtained using an Infinity guide catheter (Stryker Neurovascular, Fremont, CA) and Catalyst 5 (Stryker Neurovascular, Fremont, CA) distal access catheter. A Synchro 2 soft microwire (Stryker Neurovascular, Fremont, CA) was advanced through Echelon 10 (Medtronic, Minneapolis, MN) microcatheter. The venous guide catheter was advanced into right internal jugular vein (IJV) and the distal access catheter was placed into sigmoid jugular junction. Injection of contrast revealed the IPS, but not the CS (Fig. 1B). A subsequent simultaneous hand injection with the microcatheter within the IPS and the diagnostic catheter in the left ICA elucidated the venous‐venous connection (Fig. 1C,) allowing for subsequent navigation and complete treatment of the fistula through IPS using target coils (Fig. 1D). Results : Given the arterial system is a high‐pressure system and the usual direction of flow of contrast would be from the high‐pressure ICA to the low‐pressure CS, injecting a simultaneous contrast bolus from the venous end would oppose the arterial contrast flow. As a result, the fistulous connection that was previously obscured became visible allowing roadmap imaging guiding navigation into the CS. Conclusions : Use of simultaneous trans‐arterial/trans‐venous contrast injection is relatively simple compared to other reported techniques to reveal an obscure connection point. It also shortens the duration of endovascular tools in the bloodstream and thus, reduces the potential complication rate. Further use of this technique on larger study samples is important to validate its general use.

Spontaneous Closure of a Carotid-cavernous Fistula after Contrast-enhanced Orbit Computed Tomography

Purpose: We report a case of spontaneous closure of a carotid-cavernous fistula (CCF) after contrast-enhanced orbit computed tomography (CT).Case summary: A 80-year-old female was referred to our clinic under suspicion of chronic angle- closure glaucoma because of persistently high intraocular pressure commencing one month prior. Slit-lamp examination revealed a conjunctival injection and corkscrew-like vessel dilatation in the left eye, and a high intraocular pressure. Dilated fundus examination revealed central retinal vein occlusion in that eye. Contrast-enhanced orbit CT revealed a dilated, superior ophthalmic vein in the left orbit, and she was transferred to our department of neurosurgery for digital subtraction angiography (DSA); this is the gold standard imaging modality for the diagnosis of direct and indirect CCFs. DSA was performed two weeks after orbit CT; however, no CCF was visible. Thereafter, the conjunctival injection and the elevated intraocular pressure improved gradually over eight months. We suspect that the CCF closed spontaneously.Conclusions: Our case highlights the fact that a CCF can close spontaneously after contrast-enhanced orbit CT; ophthalmologists may wish to bear this in mind.

Analysis of Early Neuroimaging Results in Patients with Acute Isolated Ocular Motor Nerve Palsy

Purpose: To evaluate the efficacy of early neuroimaging in patients with acute isolated 3rd, 4th, and 6th nerve palsy.Methods: Neuroimaging tests were performed in patients &gt;50 years old with acute isolated 3rd, 4th, and 6th nerve palsy. The frequencies and types of abnormal findings were evaluated. All patients were divided into ischemic and non-ischemic groups and differences in clinical characteristics between groups were analyzed.Results: Of the 55 patients, nine (16.4%) had abnormal findings on brain imaging. Among 26 patients with 6th nerve palsy, four (15.4%) were found to have a cause including brain tumor, cerebrovascular compression, carotid cavernous fistula. Superior oblique muscle atrophy was found in two of 19 patients (10.5%) with 4th nerve palsy. Three of 10 patients (30%) with 3rd nerve palsy had abnormal findings and there were cases of pituitary apoplexy, posterior communicating, and cerebrovascular compression.Conclusions: In patients with acute isolated oculomotor paralysis, early neuroimaging tests play an important role in differential diagnosis and evaluation of causes that may lead to mortality.

Technique to "Trap" a Segment of the Middle Meningeal Artery for Embolization of a Carotid Cavernous Fistula: 2-Dimensional Operative Video.

Transvenous embolization is the favored treatment for indirect carotid-cavernous fistulas (CCFs). However, transarterial embolization can be used as an alternative method when the venous route is inaccessible. We present the case of a 47-yr-old woman with a history of diplopia, headaches, and sixth cranial nerve (CN-VI) palsy who presented with acute worsening of headache and ophthalmoplegia and rise of intraocular pressures. Angiography demonstrated a left indirect CCF (dural arteriovenous malformation) with multiple arterial feeders from the internal carotid artery as well as the middle meningeal artery (MMA) (Barrow type D). Transvenous approach was attempted first but was unsuccessful due to difficult access to the cavernous sinus. Thus, transarterial embolization through the MMA feeding branches was planned. To avoid occluding distal branches of the MMA by Onyx, we coiled it distally. In addition, we used a scepter balloon proximally to prevent the reflux of Onyx into potential collaterals to cranial nerves from proximal MMA. After trapping a segment of the MMA, Onyx was injected into the CCF fistula through the small MMA feeders. A postembolization arteriogram showed obliteration of the CCF. The patient developed mild left facial nerve paresis on the first postoperative day (thought to be related to partial embolization of tiny arteries in the facial canal), which was resolving in the course of hospitalization. She remained neurologically stable, and was discharged on the third postoperative day. To the best of our knowledge, this is the first report of transarterial embolization of CCF by distal coiling and proximal ballooning to trap a segment of an artery. The authors hereby confirm that informed consent was obtained from the patient after thorough discussion of the procedure's rationale, risks, benefits, and alternatives.

Hypercoagulability in patients with indirect carotid cavernous fistulas.

To assess patients with indirect carotid-cavernous fistulas (CCF) for evidence of hypercoagulable state (HS) by combination of comprehensive medical questionnaire and laboratory testing. Patients with confirmed diagnosis of CCF treated between 2003 and 2019 were included and administered a questionnaire screening for HS risk factors and undergone laboratory investigations which included complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibody titres), Factor V Leiden, prothrombin, protein C, protein S, antithrombin III, homocysteine, prothrombin G20210, CALR and JAK2 mutation screening. Participants with abnormal laboratory testing and/or past history of ischemic stroke, atrial fibrillation, cancer or hypercoagulability-associated hereditary disorders were deemed to have HS. Twenty-two patients were enrolled. Seventeen were women and the mean age at diagnosis was 60. Fourteen (64%) had evidence of HS: six on medical history, three with laboratory evidence and five with both. Eight (36%) had current abnormal hypercoagulability markers. One had a diagnosis of Klippel-Trenaunay Syndrome, but no others had evidence of hereditary thrombophilia. Nine were on anti-coagulation initiated after diagnosis of stroke or atrial fibrillation discovered on average 5.5 years after the diagnosis of CCF. A total of 64% percent of patients with previous indirect CCF had evidence of underlying HS indicating that hypercoagulability might play a role in the pathogenesis of CCF. The results support need for comprehensive testing for underlying HS in patients with indirect CCFs to better identify, manage, and prevent further thromboembolic events.

153 Carotid-Cavernous Fistula Causing Bradycardia Following Maxillofacial Trauma: A Case Report

Abstract A 53-year-old male presented to the local A&amp;E department with a fractured mandible following a single punch to the lower face, and was admitted under Oral &amp; Maxillofacial Surgery. A subsequent finding was chemosis, relative afferent pupillary defect, minimal soft exophthalmos, reduced visual acuity and colour vision in one eye, but with no associated trauma to the orbits. A CT scan showed no sign of other injury, no blood collection, and the small amount of orbital emphysema didn’t appear to be the cause of symptoms. A heart rate of 40bpm was observed, with ECG and telemetry ruling out cardiac causes of bradycardia. With this clinical picture and no orbital space occupying lesion or collection identified on the CT scan, an MRI of the head was requested, which showed superior ophthalmic vein occlusion, resulting in a diagnosis of a direct carotid-cavernous fistula (CCF). The proptosis increased slowly over 24 hours and became pulsatile. The patient was subsequently referred to the tertiary centre for treatment with endovascular embolisation using coils, which resulted in full resolution of the signs and symptoms. This case presents a rare acute presentation of CCF after indirect trauma. It is assumed that bradycardia was caused via the oculo-cardiac reflex. This presentation could have led to a clinical diagnosis of retrobulbar haemorrhage or tension pneumo-orbit, triggering surgical or needle decompression of the orbit. Such treatment would have had catastrophic consequences. This is a reminder to consider this rare diagnosis and cause of bradycardia after facial trauma.