Direct Carotid-cavernous Fistula Research Articles

Treatment of Traumatic Direct Carotid-Cavernous Fistula with a BeGraft-Covered Stent.

The widely accepted option for treating traumatic direct carotid-cavernous fistula (dCCF) has been endovascular treatment using detachable balloons, coils, or embolic agents. Covered stent deployment has been applied by a few operators and has shown promising results. This is a retrospective study on patients with dCCF treated by an endovascular approach using BeGraft, a covered stent. In 4 cases, this device was successfully deployed without any complications. Immediate complete occlusion was achieved in 3 patients (75%) after deployment of the covered stents. One patient required transvenous coiling for occlusion of the remaining endoleak. Follow-up imaging demonstrated 100% fistula occlusion with complete internal carotid artery patency. No early or late complications occurred following treatment. In conclusion, the BeGraft-covered stent could be a promising safe and effective alternative option for the endovascular treatment of dCCF.

Direct carotid cavernous fistula treated with transvenous approach: A case report

Introduction: Carotid cavernous fistulas are uncommon vascular abnormalities marked by anomalous connections between the carotid artery and the cavernous sinus. We present a case of a direct carotid cavernous fistula and its successful treatment in a 42-year-old female. Case presentation: A 42-year-old female presented with right eye painful swelling and visual disturbance. She had no known comorbidities or history of injury. Examination showed proptosis, chemosis, and orbital bruit. Carotid angiography confirmed a carotid cavernous fistula, which was managed endovascularly. The patient fully recovered after treatment. Discussion: Carotid cavernous fistula occurs spontaneously or as a result of trauma or other vascular abnormalities. Common clinical manifestations include proptosis, chemosis, and orbital bruit, with vision loss being a feared complication. Diagnosis is typically confirmed through angiography, with digital subtraction angiography being the gold standard. Endovascular treatment is usually effective, although surgical management may be necessary in certain cases. Conclusion: Carotid cavernous fistula is a rare but potentially sight-threatening neurological condition. Treatment with transvenous approach is effective for management of direct carotid cavernous fistula.

Balloon Assisted Transvenous Coil Embolization of Posttraumatic Direct Carotid-Cavernous Fistula with the Successful Outcome: A Case Report

A carotid cavernous fistula (CCF) is an abnormal connection between the internal carotid artery and the cavernous sinus. This case pertains to a 19-year-old male who presented with left periorbital swelling following a road traffic accident and was found to have direct CCF on imaging. The patient underwent balloon-assisted transvenous embolization, with access to the fistula being gained through the femoral vein and the inferior petrosal sinus. The use of coils successfully blocked the fistula, leading to the resolution of symptoms without any complications. This case underscores the significance of a multidisciplinary approach and the effectiveness of balloon-assisted embolization.

Evaluating the diagnostic performance of non-contrast magnetic resonance angiography sequences in the pre-procedural comprehensive analysis of direct carotid cavernous fistula.

Endovascular treatment of direct carotid cavernous fistula (DCCF) requires invasive diagnostic cerebral angiography for diagnosis and planning; however, a less invasive modality like magnetic resonance angiography (MRA) can be useful, especially in high-risk cases. This single-centre study evaluated a newer MR angiography (MRA) sequence, silent MRA and the traditional time of flight (TOF) MRA for pre-procedural treatment planning of DCCF. All consecutive DCCF patients who underwent TOF, silent MRA and diagnostic cerebral angiography were included in the study. Angiographic features like rent size, location, draining veins and collateral communicating arteries were analysed and compared between the two MRA sequences, with digital subtraction angiography (DSA) as the gold standard. Fifteen patients were included in the study. TOF MRA exhibited better sensitivity (76.9% vs 69.2%) in identifying the rent location, correctly pinpointing the location in 93.3% compared to 73.3% with silent MRA. Both MRA sequences showed good agreement with DSA for primary sac and rent size. TOF MRA correctly identified 86.2% of 210 total venous structures compared to 96% by silent MRA. Silent MRA demonstrated higher sensitivity (90% vs 76%) and accuracy (87.69 vs 94.36) in visualisation of involved veins compared to TOF MRA. Arterial characteristics of DCCF like rent location and rent size were better assessed by TOF MRA. Although both MRA identified venous features, silent MRA correlated better with DSA irrespective of the size and proximity to the site of the fistula. Combining both sequences can evaluate various angioarchitectural features of DCCF useful for therapeutic planning.

Covered Stent Treatment for Direct Carotid-Cavernous Fistulas: A Meta-Analysis of Efficacy and Safety Outcomes

BackgroundDirect carotid-cavernous fistulas (dCCFs) involve the abnormal shunting of blood between the internal carotid artery and the cavernous sinus. The use of covered stents (CSs) has been reported for the treatment of complex carotid artery lesions. However, the efficacy and safety of CS treatment for dCCFs remain controversial. Thus, we performed a systematic review and meta-analysis to evaluate these efficacy and safety endpoints. MethodsA systematic literature review was performed by comprehensively searching the Medline, Embase, and Web of Science databases to identify studies that were related to CS treatment for dCCFs. Then, a meta-analysis was conducted to pool the efficacy and safety outcomes from these studies based on perioperative and follow-up data. ResultsFourteen non-comparative studies enrolling 156 patients with 160 dCCFs met the inclusion criteria. When analyzing perioperative outcomes, the technical success rate was 98.5% [95% confidence interval (CI), 0.948, 1.000], and the immediate complete occlusion rate was 90.9% (95% CI, 0.862, 0.959). Vasospasm and dissection occurred in 32.2% (95% CI, 0.238, 0.463) and 0.1% (95% CI, 0.000, 0.012) of patients, respectively. The in-stent acute thrombus formation rate was 0.1% (95% CI, 0.000; 0.013). Postoperatively, the mortality rate was 0.1% (95% CI, 0.000, 0.013). Based on available follow-up data, the final complete occlusion and parent artery stenosis rates were 99.3% (95% CI, 0.959, 1.000) and 18.6% (95% CI, 0.125, 0.277), respectively. ConclusionsCS placement can be used to safely and effectively treat dCCFs. These results provide a reference for future clinical trials.

Deconstructive repair of a direct carotid-cavernous fistula via a posterior circulation retrograde approach.

We report a case of a 24-year-old patient who presented after a head trauma with a traumatic occlusion of his left internal carotid artery. He underwent diagnostic cerebral angiogram and was found to have a direct left carotid-cavernous fistula (CCF) with retrograde filling from the posterior circulation across the posterior communicating artery. Because of the severe injury to the left internal carotid artery (ICA), reconstructive repair of the ICA was not possible. The patient underwent deconstructive repair of the CCF by coil embolization using a posterior retrograde approach. Coils were successfully placed in the cavernous sinus and back into the left ICA with complete cure of the CCF and restoration of cerebral perfusion distal to the treated CCF. We review the types of CCFs, their clinical presentation, and their endovascular treatments. Retrograde access of a direct CCF is rarely reported in the literature, and we believe this approach offers a viable alternative in appropriately selected patients.

Transorbital embolization of a direct carotid-cavernous fistula with vascular steal phenomenon

Transorbital embolization of a direct carotid-cavernous fistula with vascular steal phenomenon

DIRECT CAROTID CAVERNOSUS FISTULA

Abstract
 Introduction : Carotid cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system, most commonly due to head trauma from a basal skull fracture creating a tear in the internal carotid artery (ICA) within the cavernous sinus.
 Case Illustration : A 15 years old girl presented with orbital pain, swelling, swishing or buzzing sounds, headache, and vision loss. Five months ago, she had a history of traumatic injury and undergone craniotomy. From physical examination Orbital ultrasound presence with dilated superior ophthalmic vein, which appears as a hollow tubular structure with no internal echo. MRI scan show a mass suggestive carotid cavernosus fistula dextra. DSA result confirmed the diagnose as direct carotid cavernosus fistula dextra as communication between internal carotid artery and sinus cavernosus. The patient was treated with neuroprotective along medication followed by endovascular treatment from the neurointervention department.
 Discussion : The classic triad of CCF includes pulsatile exophthalmos, chemosis and orbital bruit. Ophthalmic manifestations of CCFs vary widely depending on underlying aetiology, type, size, location, blood flow rate and drainage route of the CCF. Patient initially undergo noninvasive imaging with orbital ultrasound and magnetic resonance imaging (MRI). Digital subtraction angiography is the gold standard in the diagnosis of CCF and must be performed before any potential intervention.
 Conclusion : This case describes a patient who was diagnose with direct carotid cavernous fistula of the right eye.

Indications for alternative endovascular techniques in carotid-cavernous fistulas: A 20-year single-center experience.

While coiling is considered the standard treatment for carotid-cavernous fistulas (CCFs), studies demonstrating excellent results using new materials, especially flow diverter (FD) stents and liquid embolisates, are becoming more frequent. The indications and effectiveness of these alternative endovascular techniques remain unclear. A total of 22 direct and 20 indirect CCFs were included in the study. These were further subdivided based on the embolic material used: coils versus FD stents for direct and coils versus liquid embolisates for indirect CCFs. The subgroups were subjected to statistical analysis. An angiographic cure was achieved in 88% of all CCFs, 93% of patients' experienced clinical improvement or remained stable. Direct CCFs were treated with coiling (41%) or with both coils and FD stents (55%). One (4%) patient with a direct CCF was treated with FD stent alone. Statistical analysis comparing these subgroups revealed a significantly higher complete occlusion rate immediately after treatment in the coiling subgroup (67% vs. 23%, p = 0.0409). The occlusion rates at the last follow-up were similar (89% vs. 85%). Indirect CCFs were treated with coiling (35%) or liquid embolisates (65%). All three periprocedural ischemic complications were recorded within the liquid subgroup, resulting in a significantly higher clinical deterioration rate (p = 0.0333). FD stents in direct and liquid embolisates in indirect fistulas did not demonstrate better angiographic or clinical outcomes compared to convetional coiling. Liquid agents carried a higher risk of ischemic complications. Alternative embolization materials should be reserved for CCFs that cannot be treated with simple coiling.

Treatment of Traumatic Direct Carotid Cavernous Fistula With a PK Papyrus Covered Stent: A Report of 2 Cases

Background Traumatic direct carotid cavernous fistulas results in a direct communication between the internal carotid artery and the cavernous sinus. Covered stents are not frequently used in neuro‐endovascular procedures due to concerns primarily about occlusion of perforating vessels. There are however several factors in direct carotid cavernous fistulas that make it more amenable to covered stenting than other diseases treated endovascularly. Methods Wepresent 2 cases of occlusion of traumatic direct carotid cavernous fistulas utilizing the PK Papyrus stent. Results In our first case, this device was successfully used as a salvage technique afterfailure of conventional techniques and in the second case it was used as primary treatment. Conclusion The properties of the PK Papyrus covered stent are promising in overcoming the difficulties of other covered stents and warrants further investigation.

Percutaneous transjugular approach without arterial monitoring for the treatment of a direct carotid-cavernous fistula with vascular Ehlers-Danlos syndrome: illustrative case.

Vascular Ehlers-Danlos syndrome (vEDS) because of COL3A1 mutations is a rare inherited collagen vascular disease associated with spontaneous arterial dissections, aneurysms, vessel rupture, and organ rupture. A direct carotid-cavernous fistula (CCF) is the most common central nervous system vascular anomaly in vEDS; however, its treatment is challenging due to extremely fragile arteries and veins. A 22-year-old woman presented with pulsatile tinnitus and mild diplopia. CCF formation without trauma, cervical dissecting aneurysms, thin skin, and multiple ligament tears, as well as a genetic analysis, led to a diagnosis of vEDS. To minimize the risk of vascular injury in the thoracoperitoneal cavity, the internal jugular vein was directly punctured and the CCF was embolized transvenously using the triple-overlay road-mapping technique without arterial monitoring. The CCF was completely occluded, and the patient showed an excellent clinical course without neurological or vascular complications. Physicians and neurosurgeons should consider vEDS when treating younger patients with spontaneous CCF without trauma and investigate the possibility of genetic abnormalities and systemic vascular pathology. Transvenous embolization of a CCF through the transjugular route using the triple-overlay road-mapping technique can minimize the risk of vascular injury in a patient with vEDS.

Three-dimensional fusion images from digital subtraction angiography for the treatment of direct carotid-cavernous fistulas: illustrative case.

Direct carotid-cavernous fistulas (dCCFs) are often treated endovascularly. However, because the dCCF is usually a high-flow shunt, it is often difficult to obtain an accurate vascular structure using conventional digital subtraction angiography (DSA). Here, the authors report a case of successfully treated dCCF using three-dimensional (3D) fused DSA images. The patient presented with tinnitus, followed by oculomotor palsy, prompting magnetic resonance imaging that indicated a dural arteriovenous fistula of the cavernous sinus. DSA was performed before treatment, and a diagnosis of dCCF due to a ruptured aneurysm was made. In this case, the 3D fused simulation images enabled the authors to obtain an accurate vascular structure, resulting in successful coil embolization. Three-dimensional fusion images from DSA provide detailed anatomical information and are useful for treating high-flow dCCFs.

Identification of a de novo Case of COL3A1-Related Ehlers-Danlos Syndrome in a Young Woman Presenting With Spontaneous Direct Carotid-Cavernous Fistula.

Identification of a de novo Case of COL3A1-Related Ehlers-Danlos Syndrome in a Young Woman Presenting With Spontaneous Direct Carotid-Cavernous Fistula.

Delayed Rupture of a Cavernous Carotid Aneurysm After Flow Diversion Resulting in Direct Carotid-Cavernous Fistula Treated With Transvenous Embolization: 2-Dimensional Operative Video.

Delayed Rupture of a Cavernous Carotid Aneurysm After Flow Diversion Resulting in Direct Carotid-Cavernous Fistula Treated With Transvenous Embolization: 2-Dimensional Operative Video.

Cavernous Carotid Aneurysm Presenting as Direct Carotid-Cavernous Fistula with Contralateral Ocular Symptoms: A Rare Case Report

ABSTRACT Carotid-cavernous fistula (CCF) resulting from intracavernous carotid artery aneurysms is uncommon. However, if rupture does occur, it can lead to a CCF, which causes sudden onset of unilateral ophthalmoplegia. In this report, we present a case of a ruptured giant intracavernous carotid artery aneurysm leading to a direct CCF with contralateral ocular features. The aim is to discuss the distinctiveness of this case and the most challenging aspects of identifying similar cases. A woman in her sixties developed a sudden direct CCF, resulting in proptosis in the opposite eye. Magnetic resonance angiography revealed that the left cavernous sinus (CS) and superior ophthalmic vein were dilated, whereas the right side was unaffected. However, digital subtraction angiography (DSA) revealed a large aneurysm in the right cavernous internal carotid artery (ICA) and a direct connection between the right ICA and CS, with venous drainage exclusively occurring in the opposite direction via the intercavernous sinus. To address the issue, the aneurysm and fistula underwent Coil and Onyx embolisation, successfully closing the fistula and leading to a regression in the orbital symptom. This presents a unique scenario of an unexpected unilateral CCF with contralateral symptoms in a direct CCF, which demands immediate attention. It is crucial to remain alert for CCF and verify the diagnosis through DSA when dealing with such patients to avoid severe outcomes. Prompt identification and intervention can enhance the patient’s chances of a positive outcome.

Patch Technique for Primary Treatment of Type A Carotid Cavernous Fistula: A Case Series and Technical Notes.

The utilization of flow diverters (FDs) in the treatment of high-flow Type A carotid cavernous fistulas (CCFs) has been described before mainly as an adjunct to the traditional endovascular techniques and rarely as a stand-alone treatment. In this study, we retrospectively evaluated our experience with FDs as the solo nonadjunctive treatment of Type A CCF with severe cortical venous reflux (CVR). A retrospective review was performed of patients with Type A CCFs who were treated using FDs' patch technique (PT). Patients' demographics, clinical data, and preoperative and postoperative ocular examination were recorded. The procedure technique, pipeline embolization device (PED) diameters, and immediate and late procedure outcomes were described. Three patients were included in this case series. All patients had history of trauma and presented with decreased visual acuity, cranial nerve II deficit, limited extraocular muscles' movement, and increased intraocular pressure (IOP). Diagnostic angiography was performed, which confirmed high-flow Type A CCF. Endovascular treatment was performed through distal radial access in 2 patients and femoral access in 1 patient by deploying 4 sequentially enlarging PEDs with immediate resolution of the ocular symptoms. Follow-up angiography confirmed complete resolution of CCF in 2 patients. One patient was lost to follow-up; however, angiogram at 4 months demonstrated residual small CCF with significant improvement from postprocedure angiogram. The patch technique using sequentially enlarging FDs is a reasonable alternative solo technique for the treatment of direct CCF symptoms and results in immediate resolution of CVR while preserving the cavernous sinus anatomy.

Teaching Neuro Images : Reversible pontomesencephalic edema caused by traumatic carotid cavernous fistula

A 45-year-old man presented with a painful bulging right eye and blindness 6 weeks after a motorcycle accident and traumatic brain injury. He had a complete right oculomotor nerve palsy and only perception of light. MRI revealed ipsilateral pontomesencephalic edema (figure, A and B). Catheter angiography showed a direct right carotid-cavernous fistula (figure, C). Two months after coil embolization, the ptosis, proptosis and ophthalmoplegia resolved. MRI revealed resolution of pontomesencephalic edema (figure, D). The presumed mechanism was transmission of arterialized pressures of the cavernous sinus via a bridging vein to the anterior pontomesencephalic vein, generating venous hypertension and vasogenic edema.1,2

Features of differential diagnosis of direct carotid-cavernous fistula. Clinical case

Traumatic brain injury can cause various pathological conditions both in the eyeball and in the cranial cavity. The presented clinical case demonstrates the features of differential diagnosis of direct carotid-cavernous fistula and secondary post-traumatic glaucoma. Direct carotid-cavernous fistula is the formation of a communication between the internal carotid artery and the cavernous sinus and the discharge of arterial blood into it. The first symptom of a carotid-cavernous fistula is a pulsating noise in the head and above the eye. The manifest signs in the clinical picture are the signs of obstruction of venous outflow from the eye and the orbit: proptosis, eyelid edema and chemosis, congestive redness of the eye, varicose subcutaneous veins of the eyelids, as well as dilated ophthalmic vein visualized by ultrasound of the orbit, ophthalmic hypertension, oculomotor disorders, state of the fundus. The clinical picture in patients with secondary post-traumatic contusion glaucoma, in addition to an increase in intraocular pressure, is characterized by the presence of a congestive redness of the eye, changes in the cornea from mild superficial opacities to more dense ones, luxation or subluxation of the lens into the anterior chamber or vitreous, destruction of the vitreous or intraocular hemorrhage. The similarity of clinical manifestations of traumatic carotid-cavernous fistula and secondary post-traumatic glaucoma can cause difficulties in differential diagnosis.

Headache, vision changes and cranial nerve palsy after head trauma.

A 43-year-old female was brought to the hospital after a ground level fall and her Glasgow Coma Scale was 15. Non-contrast head computed tomography (CT) scan showed small bilateral subdural hematomas, left traumatic subarachnoid hemorrhage, left occipital bone and left longitudinal temporal bone fractures. She was managed conservatively. Interval repeat non-contrast head CT scans showed resolution of the hemorrhage. Two and a half months later she presented to the hospital with headaches, intermittent diplopia, blurry vision and a right lateral gaze palsy. Non-contrast head CT scan showed mild hyperattenuation in the cavernous sinus. Subsequently, a CT angiogram of the head was obtained that showed opacification of the bilateral cavernous sinus and distention of the orbital veins (Figure 1A,B). Evaluation with diagnostic cerebral angiogram showed direct bilateral carotid-cavernous fistulas (CCFs) (Figures 2 and 3). She underwent staged embolization of the CCFs. Direct CCF is the abnormal connection between the internal carotid artery and the cavernous sinus.1, 2 CCFs can present with the classic triad of chemosis, pulsatile proptosis and ocular bruit.3, 4 Other symptoms include orbital pain, abducens nerve palsy, deterioration of visual acuity and ophthalmoplegia.4, 5 Causes of CCF formation are traumatic, iatrogenic, connective tissue disorders and spontaneous.2, 6-9 Traumatic CCFs formation occurs in up to 1.25% of patients with traumatic brain injury or facial and skull base fractures.10, 11 Bilateral CCF formation is rare after trauma and symptoms develop in a delayed fashion.10-15 Treatment options include conservative management, open surgery, endovascular procedures and radiosurgery.16-18

Direct and Dural Carotid Cavernous Sinus Fistulas: Comparison of Clinical Characteristics.

To compare the clinical characteristics of patients with direct and dural carotid cavernous sinus fistulas (CCFs). The medical records of 60 patients diagnosed with CCFs were retrospectively reviewed. The collected data included demographic characteristics, clinical findings, and ocular manifestation. The clinical characteristics of the direct and the dural CCFs were compared on head-to-head basis. Logistic regression analysis was used to demonstrate the direction and magnitude of the difference and reported as odds ratio with its 95% confidence interval. There were 28 patients (46.67%) with direct CCFs, and 32 patients (53.33%) with dural CCFs. Patients with direct CCF were mostly male (p=0.023), younger age (p<0.001), had history of trauma (p<0.001), and more visual impairment at presentation (p=0.025), when compared to those with dural CCFs. In addition, patients with direct CCF had significantly more chemosis (p=0.005), proptosis (p=0.042), bruit (p<0.001) and dilated retinal vessels (p=0.008) than those with dural CCF. Thirty patients (50%) had increased intraocular pressure (IOP). Mean IOP of the affected eyes was significantly higher than the unaffected eyes (p<0.0001). In patients with normal IOP, mean IOP of the affected eyes was also higher than the unaffected eyes (p=0.0027). Patients with direct CCF were younger age, associated with trauma, and more visual impairment at presentation. Chemosis, proptosis, bruit and dilated retinal vessels were detected more in the direct CCF than the dural CCF. Despite normal IOP, affected eyes had significantly higher IOP than the unaffected eyes. Information on these clinical characteristics may be helpful in discrimination of the direct type, which is more urgent for further investigation and treatment.