Carotid-cavernous Fistula Research Articles

Vascular emergencies in neuro-ophthalmology.

The cerebral vascularization is assured by the 2 internal carotids and 2 vertebral arteries, and the Willis circle. Carotid artery obstruction is the most common abnormality associated with ocular ischemic syndrome. Obstruction may be due to atheromatous plaque, external compression, arteritis, or dissection of the artery. An atheromatous lesion of the carotid artery is the most frequent lesion responsible for ocular ischemic syndrome. The signs and symptoms of ocular ischemic syndrome are associated with severe hypoperfusion of the eye. Inflammatory lesions of the carotid artery are responsible for decreased flow in the carotid system. Other vascular emergencies are carotid artery dissection, Horton arteritis, aneurysms and carotid-cavernous fistula. The most common ocular signs and symptoms are transient monocular blindness, persistent monocular blindness, ocular ischemia, Claude Bernard Horner syndrome and oculomotor palsies.The carotid pathology can be a life-threatening pathology and it is important to recognize all these signs and symptoms. A multi-specialty approach will prevent misdiagnosis and lead to a better patient management.Abbreviations: OIS = ocular ischemic syndrome, TMB = transient monocular blindness, TIA = transient ischemic attack, ESR = erythrocyte sedimentation rate, CRP = C reactive protein, NVE = neovascularization elsewhere in the retina, NVD = neovascularization on the disc, AION A = anterior ischemic arteritic optic neuropathy, CBH = Claude Bernard Horner syndrome, MRI = magnetic resonance imaging

Delayed Onset Cranial Nerve Palsy After Transvenous Embolization of Indirect Carotid Cavernous Fistulas

Wang, Arthur MD; Mandigo, Grace K MD; Lavine, Sean D MD; Meyers, Philip M Author Information

Successful Endovascular Treatment for Recanalized Post-Traumatic Carotid-Cavernous Fistula

Carotid-cavernous fistulas (CCFs) are spontaneous or acquired communications between the internal carotid artery (ICA) and the cavernous sinus, which can be classified as direct or indirect. Direct fistulas between the ICA and the cavernous sinus can arise from injury, rupture of intracavernous carotid aneurysm, collagen deficiency syndrome, artery dissection, fibromuscular dysplasia, and direct surgical trauma. The symptoms caused by CCF are related to their size, duration, location, the direction of venous outflow, and the presence of arterial and venous collaterals. The goal of treatment for direct CCFs is to close the defect between the ICA and the cavernous sinus while maintaining the patency of the ICA. This goal can be achieved either by transarterial fistula occlusion using a removable balloon, transarterial or transvenous occlusion of the ipsilateral cavernous sinus with coils or other embolic material, or by implanting a covered stent in the fistula area. The choice of a method for CCF treatment remains relevant. The paper describes a clinical case of successful endovascular treatment for post-traumatic recanalized CCF in a patient with obvious ophthalmic manifestations as pulsating exophthalmos, conjunctival chemosis, and ischemic optic neuropathy of the right eye. Previously, the patient had undergone endovascular CCF embolization with coils and ICA reconstruction with flow diverting stents. Fistula embolization was performed with coils via transvenous access. In the opinion of the authors, the use of venous access in this case allowed them to perform total occlusion of the recanalized fistula and to achieve good angiographic and clinical results in the long-term period.

Results of Endovascular Treatment for High-Flow Direct Carotid-Cavernous Fistulas

Objective : to study the results of treatment in patients with direct high-flow carotid-cavernous fistulas with their transarterial occlusion using detachable balloons and microcoils. Material and methods. Thirty-five patients underwent surgery using detachable balloons and microcoils. The clinical picture in all patients was represented by pulsating exophthalmos, ptosis on the side of the lesion, ophthalmoplegia, and conjunctival chemosis. Results. In all patients closure of carotid-cavernous fistulas and reversal of symptoms were achieved after primary surgery. Internal carotid artery reconstruction with microcoils could be achieved significantly more often than that with balloons. An anastomotic recurrence was significantly more common in patients undergoing surgery with balloons. Conclusion. The use of microcoils allows to perform reconstructive surgery significantly more frequently, while the recurrence rate is significantly lower than after using the balloons.

Gaining Access to the Superior Ophthalmic Vein for Endovascular Embolization of Indirect Carotid-Cavernous Fistulas

Carotid-cavernous fistulas (CCFs) are abnormal connections between the carotid arterial system and the cavernous sinus. These acquired vascular malformations may result in severe orbital congestion and sight-threatening complications. The authors present their experience in gaining access to the superior ophthalmic vein to embolize indirect CCFs in three different patients. Surgical exposure and cannulation of the SOV were successful in all 3 cases. One patient developed an orbital compartment syndrome towards the end of the embolization process, after the irrigation cannula was inadvertently dislodged from the SOV. He required a lateral canthotomy and inferior cantholysis but did not suffer from any related sequelae. Signs and symptoms resolved gradually in all patients and cosmetic results were excellent. In our experience, the SOV offers a reliable access to indirect CCFs, but patients should be monitored closely during the embolization process to prevent ophthalmic complications.

Operative Nuances of Blind Catheterization of Occluded Sinuses Using Negative Road Map Technique: 2-Dimensional Operative Video.

Dural arteriovenous fistula (DAVF) are often treated with endovascular transvenous embolization. DAVFs though, are often associated with intracranial venous sinus occlusion, which limits the transvenous route. Here, we present the operative nuances of blind catheterization of an occluded dural venous sinus in 2 different cases with DAVF. First case is a 72-yr-old patient with indirect right carotid-cavernous fistula associated with an occluded inferior petrosal sinus, with severe orbital congestion. Second patient is a 79-yr-old patient with a new external carotid to a trapped transverse sinus fistula (Cognard IIA+B), extensive cortical venous reflux in the setting of an occluded sigmoid sinus. In both cases, the transarterial route was limited because of small arterial feeders thus, after obtaining patients' consent, we performed transvenous sacrifice of the isolated sinus. In both cases, the occluded sinus was transvenously blindly retrograde probed using a 0.035 inch Terumo Glidewire (Terumo Medical Corporation, Somerset, New Jersey). Once the occluded segment was probed, a dark roadmap was acquired with the wire in place. This created a negative roadmap once the guidewire is removed. This negative roadmap is used to navigate the microcatheter-microwire into the isolated sinus. In the first case, the cavernous sinus and the superior ophthalmic veins were sacrificed with coils. In the second patient, the entrapped left transverse sinus was embolized using Onyx. In both cases, complete occlusion of the fistula was attained. In this neuroendovascular video, we demonstrate the nuances of blind catheterization of an occluded sinus using a negative roadmap technique as guidance for the micro-catheterization. Institutional Review Board approved. Patient consent not required due to retrospective nature of manuscript, based on medical chart and imaging reviews, anonymized in the video.

FISTULE CAROTIDO-CAVERNEUSE GEANTE POST-TRAUMATIQUEGIANT TRAUMATIC CAROTID-CAVERNOUS SINUS FISTULA

Carotid-cavernous fistulas are abnormal arteriovenous communications between the carotid system and the cavernous sinus [1]. They are rare but potentially serious, which can engage the functional and vital prognosis. We report the case of a young patient who presented a giant carotid-cavernous fistula following a road accident with a cranial impact point.

Endovascular Treatment of Complex Vascular Diseases of the Internal Carotid Artery Using the Willis Covered Stent: Preliminary Experience and Technical Considerations.

Purpose: The Willis covered stent (WCS) is used to treat complex vascular diseases of the internal carotid artery; however, its performance requires further investigation. This study aimed to present our single-center clinical results and experience of endovascular repair of complex vascular diseases of the internal carotid artery using the WCS.Methods: Patients who presented with complex vascular diseases of the internal carotid artery and who were treated with the WCS from December 2013 to September 2018 were retrospectively reviewed. Procedural results, perioperative complications, incidence of endoleak, and follow-up outcomes were analyzed.Results: Sixty-five patients were enrolled. A total of 25 large aneurysms, 10 pseudoaneurysms, 14 blood blister-like aneurysms, 11 carotid–cavernous fistulas, and 5 surgical injuries were assessed. WCS placement was successful in all patients. Immediate angiography showed that complete repair of the target artery was achieved in 56 patients (86.2%). Endoleak was observed in nine patients, including seven type I endoleaks and two type II endoleaks. Occlusion of a side-branch vessel occurred in four patients. Acute in-stent thrombosis occurred in one patient. No ischemic or hemorrhagic events or other complications developed during the perioperative and follow-up periods. Angiographic follow-up (mean duration, 12 ± 3.29 months) was performed in 60 patients and showed complete target artery repair in 58 patients, and asymptomatic mild to moderate in-stent stenosis was observed in four patients. Slight endoleak persisted in two patients without enlargement or rupture of the residual lumen.Conclusion: WCS implantation is safe, feasible, and efficacious for endovascular repair in patients with complex vascular diseases of the internal carotid artery, showing excellent short-term target artery patency and clinical outcomes.

Delayed Onset of Mixed Cranial Neuropathies and Cluster Headache After Embolization of Indirect Carotid-Cavernous Fistula.

Delayed Onset of Mixed Cranial Neuropathies and Cluster Headache After Embolization of Indirect Carotid-Cavernous Fistula.

Apraclonidine for the pharmacologic confirmation of acute Horner syndrome

Apraclonidine is the most widely used pharmacologic agent to confirm Horner syndrome. It is a strong α-2 and a weak α-1 adrenergic agonist and reversal of anisocoria is considered a positive test. The utility of apraclonidine in acute Horner syndrome remains controversial as the exact timing for denervation sensitivity to develop remains unknown. The goal of this study was to describe the use of apraclonidine in the diagnosis of acute Horner syndrome in patients with an unequivocal onset within 7 days. We identified 3 patients who were referred to ophthalmology/neuro-ophthalmology service and had reversal of anisocoria within 7 days. Two cases of second-order Horner syndrome after cardiac surgery and a case of a third-order Horner syndrome from a carotid cavernous sinus fistula resulted in reversal of anisocoria 72 h, 48 h, and 5 days after onset. Photographic documentation was provided for all cases. Our results suggest that apraclonidine has utility in the acute period and positive results can be seen as early as 48 h after onset. Apraclonidine should therefore still be considered to confirm the presence of acute Horner syndrome before extensive neuroimaging is performed.

Superior ophthalmic vein thrombosis post manual carotid compression for indirect carotid-cavernous fistula

ABSTRACT Purpose To report 5 cases of superior ophthalmic vein thrombosis (SOVT) following intermittent manual carotid compression (IMCC) for indirect carotid-cavernous fistula (CCF) and to outline the management. Methods Retrospective observational case series of all patients who developed SOVT secondary to IMCC for indirect low flow CCF’s at a tertiary care center. The demographic profile, clinical, imaging findings, treatment, and outcomes were studied. Results The mean age at presentation was 60.2 years (Range: 42–87 years). Four patients were male. All patients had a unilateral presentation. The mean time interval between starting IMCC and the development of SOVT was 1.18 months (Range: 0.25–3 months). Acute exacerbation of proptosis and chemosis associated with a decrease in vision was the presenting feature in all the patients. The mean visual acuity at presentation was 0.89 on the logMAR scale. The causes of reduced visual acuity were venous stasis retinopathy (n = 4) and compressive optic neuropathy (n = 1). Magnetic resonance imaging revealed enlarged superior ophthalmic vein with absent flow voids and post-contrast filling defects. Four patients received anticoagulation treatment with subcutaneous injection of enoxaparin 1 mg/kg twice daily for 5 days followed by oral warfarin 5 mg once daily along with oral steroids. Complete recovery of SOVT was noted in all patients at a mean duration of treatment of 0. 75 months (Range: 0–2 months). Conclusion SOVT is a rare but possible complication in patients on IMCC for indirect CCF, and hence warrants close follow up. Early diagnosis and prompt management will help in preventing complications like permanent vision loss.

Neuro-Endovascular Intervention in Traumatic Carotico-Cavernous Fistulae: A Single-Center Experience.

IntroductionThe aim of this research was to describe a single-center practical experience in the management of traumatic carotid cavernous fistula (CCF).MethodsThere were a total of 31 patients between January 2005 and December 2019 with post-traumatic carotid cavernous sinus fistula (tCCF) who underwent treatment. We classified them into 2 types according to the flow of the CCF: patients with high flow CCF and patients with low flow CCF.ResultsAngiography revealed the high flow types on 21 patients (67.7%), the mean of patients ages are 31.5 years. Onyx embolization was performed in 1 patient (4.76%), transarterial balloon embolization was carried out in 10 patients (47.61%), transarterial coiling in 3 (14.28%) patients while 5 (28.8%) patients underwent transvenous routes to insert the coil and 2 patients (9.52%) were treated conservatively. Complete occlusion was achieved on all patients with coiling whereas the other treatment experiences the reducing flow of the fistula. We obtained 10 patients (32.2%) with a mean of 40.3 years as low flow type CCF. The patients with the low flow type mostly treated conservatively, because their symptoms were acceptable and intermittent.ConclusionThe ballooning currently became the more affordable treatment in our center. Balloon embolization was recommended for medium- and large-size fistula. The coils should be recommended for small-size fistula. In some cases occlusion of the fistula cannot be obtained using the detachable balloon, a coil can be used to occlude the cavernous sinus via trans arterial or trans venous access. If the fistula failed to be treated in traditional ways using balloons or coils, occlusion of the parent vessels could be another option.

Gunshot wounds of the head in peacetime, with the formation of a delayed carotid-cavernous fistula (case report)

The objective of the article is to present the clinical observation of a gunshot wounds of the head in peacetime, with the formation of a delayed carotid-cavernous fistula.Clinical case. A patient aged 26 years received a penetrating parabasal single gunshot wound to the head. After transfer to the N.V. Sklifosovsky Research Institute of Emergency Medicine from a local hospital, intima dissection and occlusion of the left internal carotid artery (ICA) were diagnosed. Supraclinoid section of the left ICA, left anterior cerebral and middle cerebral arteries were filled from the right ICA through the anterior communicating artery. For prevention of suppurative-septic complications as well as decubitus of the left ICA and development of life-threatening hemorrhages, repeat surgery was performed. Acute subdural hematoma and brain detritus were removed. Using pterional approach, the chiasm and sellar region was accessed. Sequentially the ophthalmic, interpenducular, penducular cisterns, cisterna laminae terminalis and left carotid cistern were dissected. Sequentially the left ophthalmic nerve, left ICA, left choroid arteries were isolated. A metallic foreign object (bullet) located in the medial regions of the larger wing of the sphenoid bone and lateral wall of the cavernous sinus was found and removed. On day 14 after the second surgery, headache became worse, pulsing noise developed in the left part of the head, as well as moderate exophthalmos on the left. Left-hand type A (per the Barrow classification) carotid-cavernous anastomosis with retrograde inflow due to occlusion of the left ICA was diagnosed. Endovascular intervention was performed: separation of the carotid-cavernous anastomosis through retrograde occlusion of the supraclinoid segment of the left ICA with microcoils through contralateral ICA and anterior communicating artery. The patient was discharged at day 30 after hospitalization. Cerebral and meningeal symptoms regressed. Ptosis grade decreased, the left eye started to move.Conclusion. This abovementioned observation is of interest due to the rarity of such pathology and the possibilities of modern multidisciplinary centers for the diagnosis and treatment of such patients as of this date.

Advantage of Balloon Guide Catheter During Endovascular Treatment of Direct Carotid-Cavernous Sinus Fistula: Technical Note and Report of 2 Cases

As previous studies reported, the balloon guide catheter is useful for identifying the fistula point during diagnosis of direct carotid-cavernous sinus fistula (d-CCF). We demonstrate an additional advantage of the balloon guide catheter during intraarterial endovascular treatment of d-CCF. Two cases of d-CCF are presented in this report. A balloon guide catheter is used to help achieve successful coil embolization of the fistula in both cases. Microcatheter positioning into the fistulous point can be easier after balloon inflation. Balloon inflation can help with coil deployment. Using a balloon guiding catheter can reduce internal carotid artery flow near the fistula point at the cavernous segment of the internal carotid artery. As a result, better identification of the fistula point can be made, which allows easier placement of the microcatheter into the fistula point and more stable coil deployment.

Syndrome de Radius-Maumenee : une cause rare de glaucome

Radius-Maumenee syndrome is a rare cause of severe secondary open-angle glaucoma. The ocular hypertension is due to episcleral venous hypertension. This syndrome consists of open angle glaucoma and episcleral venous dilatation without orbital or systemic abnormalities. It is diagnosis of exclusion after ruling out carotid-cavernous fistula, thyroid orbitopathy and an invasive orbital process that might explain the elevated episcleral venous pressure. Treatment begins with glaucoma eyedrops and, in case of failure, filtering surgery. Uveal effusion syndrome and postoperative choroidal detachment are frequent complications of filtering surgery in patients with this syndrome. We present the case report of a 59-year-old woman with Radius-Maumenee syndrome.

Shunt Site Localization of Direct Carotid-Cavernous Fistula Using 3D Rotational Angiography—Utility of Broken-Rim Sign

Direct carotid-cavernous fistulas (DCCF) develop due to breach in the integrity of the wall of the internal carotid artery, and its localization can sometimes be difficult due to rapid high flow shunts. We hypothesized that 3D rotational angiography could locate the fistula site accurately, where an interrupted rim of the carotid wall would be silhouetted against opacified vascular structures. This finding was described as a broken-rim sign, and in this study, we assessed the utility of this sign in the localization of the shunt point of DCCF. Retrospective analysis of 15 cases of DCCF was performed, and the rent was characterized based on the broken-rim sign. Two observers independently evaluated the results and compared them against the intraoperative observations. The broken-rim sign was identified and correlated with the actual fistula site in 86.6% and 100% of patients by observers 1 and 2, respectively. The inter-rater agreement was 0.87 (P < 0.001). Misinterpretation was made in 2 patients by 1 observer, due to poor contrast opacification of the vascular structures secondary to very rapid shunting and mild movement artifacts. Our study highlights the role of 3D rotational angiogram and analysis of the carotid wall in the localization of the shunt site in DCCF. The broken-rim sign accurately points to the location of the fistula.

Long Term Post Traumatic High Flow Carotid Cavernous Fistula with Patent Collateral Vessel : A Case Report

Introduction : A carotid-cavernous sinus fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus. Carotid cavernous fistula (CCF) is a very rare case it's difficult to diagnose. because most CCF patients rarely come for treatment. Case Report : A 33-year-old male presented with history of protrusion of Left eye ball, and double vision for the last 2 years. visual disturbances were found in the right eye for 2 years, blurry vision is increasingly. Bruit was audible in orbital region on the left side. DSA showed that there was a fistula in the left sinus cavernous region, the arteries in the left area showed inadequate to direct the left hemisphere, but in the right arety showed that the right artery was adversely affected right and left brain. Discussion : Traumatic CCFs are the most common type, accounting for up to 75% of all CCFs.87 They have been reported to occur in 0.2% of patients with craniocerebral trauma and in up to 4% of patients who sustain a basilar skull fractur.2 The symptoms and signs of CCF always include eyelid swelling, proptosis, chemosis, and hyperaemia, dilated of vessel and the condition is commonly misdiagnosed as Graves’ophthal-mopathy or inflammatory conjunctivitis.3Cerebral angiography is the gold standard for the definitive diagnosis, classification, and planning of endovascular intervention in CCFs. Angiographic results in this patient showed a fistula in the left cavernous sinus and inadequate supply of the left artery to the left hemisphere. Conclusion : This case is very unique because the left brain gets blood supply from the right carotid system, with the left carotid artery system inadequate to direct the left hemisphere because of the carotid cavernous fistula on the left side

Delayed-Onset Cranial Nerve Palsy After Transvenous Embolization of Indirect Carotid Cavernous Fistulas.

Carotid cavernous fistulas (CCF) often present with diplopia secondary to cranial nerve palsy (CNP). Immediate development of postoperative CNP has been described in the literature. This study described delayed-onset of CNP after complete and reconfirmed obliteration of the CCF and resolution of initial CNP. A retrospective analysis was performed on patients with indirect CCF between 1987 and 2006 at 4 academic endovascular centers. Details of the endovascular procedures, embolic agents used, and complications were studied. Partial or complete obliteration was determined. Immediate and delayed cranial nerve palsies were independently assessed. A total of 267 patients with symptomatic indirect CCF underwent transvenous endovascular treatment. Four patients (1.5%) developed delayed abducens nerve (VI) palsy after complete resolution of presenting symptoms after embolization. Delayed presentation ranged between 3 and 13 months after complete resolution of initial double vision and cranial nerve palsies. Transvenous coil embolization through the inferior petrosal sinus was performed in all 4 affected patients. All had follow-up angiography confirming durable closure of their CCF. MRI did not show new mass lesions or abnormal soft tissue enhancement. In all 4 patients, their abducens nerve (VI) palsy remained. Delayed CNP can develop despite complete endovascular obliteration of the CCF. The cause of delayed CNP is not yet determined, but may represent fibrosis and ischemia. Long-term follow-up is needed even after complete neurological and radiological recovery is attained in the immediate perioperative period.

Delayed rupture of intracranial aneurysms after placement of intra-luminal flow diverter.

Though flow diverter is a safe and efficient modality, some patients can experience delayed aneurysmal rupture. The mechanism of delayed rupture is still obscure to us. We performed a systematic search in the PubMed database for patients with delayed rupture of intracranial aneurysms after flow diverter placement. A total of 36 articles reporting on 60 patients were included in the final analysis. Of the 49 patients with description of presenting symptoms, six (12.2%) patients were incidentally diagnosed, 39 (87.8%) patients were admitted for aneurysmal rupture or mass effect. Multiple flow diverters were used in 38.3% (18/47) of the patients. Coil assistance was applied in 13.0% (7/54) of the patients. Delayed aneurysmal rupture led to intracranial hemorrhage or carotid-cavernous sinus fistula (CCF) in 76.8% (43/56) and 23.2% (13/56) of the patients, respectively. Of the 55 patients with description of outcome, 14 (25.5%) patients achieved good recovery, one (1.8%) patient was severely disabled, 40 (72.7%) patients died. All of the patients in the CCF group survived and experienced good recovery. Increased intra-aneurysmal pressure, destabilization of the aneurysm wall by intra-aneurysmal thrombus, persistent residual intra-aneurysmal flow, characteristics of the specific aneurysm, and mechanical injury by the flow diverter might conjointly contribute to the final delayed rupture. There has been no established preventive measure to decrease the incidence of delayed rupture yet. The treatment and outcome depend on the presentation of delayed rupture. Patients presenting with aneurysm-related intracranial hemorrhage have a dismal outcome. Those presenting with CCFs usually have a satisfactory recovery.

Thin-Section MR Imaging for Carotid Cavernous Fistula.

Carotid-cavernous fistulas are abnormal vascular shunts that can cause various neurologic or orbital symptoms. The purpose of this retrospective study was to evaluate the diagnostic performance of thin-section MR imaging for carotid cavernous fistula in patients with clinically suspected carotid cavernous fistula, and to identify possible imaging predictors of carotid cavernous fistula. A total of 98 patients who were clinically suspected of having carotid cavernous fistula (according to their symptoms and physical examinations) between January 2006 and September 2018 were included in this study. The patients underwent pretreatment thin-section MR imaging and DSA. Thin-section MR imaging consisted of 2D coronal T1- and T2WI with 3-mm thickness and 3D contrast-enhanced T1WI with 0.6 mm thickness. The diagnostic performance of thin-section MR imaging for carotid cavernous fistula was evaluated with the reference standard of DSA. Univariate logistic regression analysis was performed to determine possible imaging predictors of carotid cavernous fistula. Among the 98 patients, DSA confirmed 38 as having carotid cavernous fistula. The overall accuracy, sensitivity, and specificity of thin-section MR imaging were 88.8%, 97.4%, and 83.3%, respectively. Possible imaging predictors on thin-section MR imaging included abnormal contour of the cavernous sinus (OR: 21.7), internal signal void of the cavernous sinus (OR: 15.3), prominent venous drainage flow (OR: 54.0), and orbital/periorbital soft tissue swelling (OR: 40.4). Thin-section MR imaging provides high diagnostic performance and possible imaging predictors of carotid cavernous fistula in patients with clinically suspected carotid cavernous fistula. Thin-section MR imaging protocols could help decide appropriate management plans for patients with clinically suspected carotid cavernous fistula.