Direct Carotid-cavernous Fistula Research Articles

Three-Dimensional Digital Subtraction Angiography for Endovascular Treatment of Direct Carotid-Cavernous Fistula -Case Report-

A 63-year-old woman with a direct carotid-cavernous fistula (CCF), manifesting as sudden onset of severe headache and pulsatile tinnitus suffered during coronary angiography, was successfully treated with transarterial embolization based on the anatomical information obtained from volume-rendered three-dimensional digital subtraction angiography (3D DSA) images. 3D DSA is useful for understanding the configuration of such fistulas accurately and devising a therapeutic strategy for the endovascular treatment of direct CCFs.

Combined transarterial, transvenous, and direct puncture of the cavernous sinus to cure a traumatic carotid cavernous fistula

Direct carotid cavernous fistulas (CCF) are generally well managed by simple endovascular treatment. We report an 8-year-old boy who required subsequent direct puncture of the cavernous sinus to completely obliterate the residual fistula after both transarterial and transvenous embolization had been performed. He presented with a mild right frontal headache, congestion of the right conjunctiva, blurred vision, and photophobia. Cerebral angiography demonstrated a right direct CCF. The patient underwent transarterial and transvenous embolization of the cavernous sinus (CS) with Gugliemi detached coils (GDCs), but a residual shunt persisted. Two days later, another session of embolization by direct puncture of the CS with GDCs was performed after failure to navigate through the superior ophthalmic vein which was partially occupied by previously deployed coils. Immediate control angiography showed complete obliteration of the fistula and the patient’s symptoms rapidly resolved. This is the first report of a patient with a CCF who required three combined approaches – transarterial, transvenous, and direct puncture of the CS – to achieve complete closure of the complexed shunt.

Percutaneous Trans-Superior Orbital Fissure Embolizationof Carotid-Cavernous Fistulas: Technique and Preliminary Results

To describe the technique of percutaneous, infraocular embolization of indirect carotid-cavernous fistulas (CCFs) and analyze the results in a small clinical series. A retrospective case series of 4 patients treated at Emory University Hospital. Four patients with indirect CCFs and limited transvenous access were successfully treated with transcutaneous, infraocular embolization of the recipient cavernous sinus via the ipsilateral superior orbital fissure. Main outcome measures were clinical examination findings and cerebral angiography. All patients had either preservation or improvement in final visual outcome. One patient required early retreatment because of clot lysis and reopening of a secondary, iatrogenic direct CCF. Two patients suffered early postprocedural orbital hemorrhage requiring treatment with lateral canthotomy and inferior cantholysis. Based these findings, percutaneous, infraocular, trans-superior orbital fissure embolization of CCFs is a viable alternative in patients with refractory fistulas failing management with more conventional techniques. Orbital hemorrhage is a significant risk, and availability of an ophthalmologist skilled in the management of this complication is imperative.

Treatment of a Traumatic Carotid-Cavernous Fistula with a Covered Stent: Some Considerations

This article discusses some considerations concerning covered stent placement in a patient with a traumatic direct carotid-cavernous fistula. Our case supports recent reports in the literature that covered stent placement can be an acceptable alternative when detachable balloon occlusion or coil occlusion of a direct carotid-cavernous fistula fails or cannot be done. Positioning of a covered stent in the internal carotid artery can be technically challenging. No specific covered stents for neurovascular use have been designed or registered. Because of limited experience with covered stent placement in the carotid artery the optimal preventive and therapeutic strategies for thromboembolic complications are not known.

Covered Stent Implantation for the Treatment of Direct Carotid-Cavernous Fistula and its Mid-Term Follow-up

Carotid-cavernous fistulas are abnormal arteriovenous communications either directly between the internal carotid artery and the cavernous sinus or between the dural branches of the internal and external carotid arteries. These fistulas predominantly present with ocular manifestations and they are treated mainly by endovascular techniques in most cases. A detailed review of the literature allowed us to make a complete analysis of the information available on the topic. We describe a case of a direct carotid-cavernous fistula occluded by endovascular implantation of a covered stent, showing the persistence of results after three years.

Placement of Covered Stents for the Treatment of Direct Carotid Cavernous Fistulas

Endovascular detachable balloon occlusion and coil occlusion are 2 well-established options for the treatment of direct carotid cavernous fistulas (DCCFs). In recent years, covered stents have been applied in the treatment of neurovascular pathologies such as aneurysms, pseudoaneurysms, arterial dissections, and DCCFs. The purpose of this study was to investigate the clinical efficacy of covered stents for the treatment of DCCFs. Ten consecutive patients underwent covered-stent placement after failure of detachable balloon occlusion for the treatment of their DCCFs. Clinical and angiographic follow-up ranged from 5 to 48 months (mean, 18.2 months) after stent placement. Stent placement was technically successful in all except 1 patient. In this patient, stent placement failed after multiple attempts because of rigidity of the Jostent GraftMaster Coronary Stent Graft and the tortuous anatomy of the internal carotid artery (ICA). Complete exclusion of the fistula was achieved in 6 patients immediately after stent deployment. Endoleak was observed in 3 patients. Re-dilation of the stent avoided the endoleak in 2 patients; in 1 of these 2 patients, formerly improved symptoms recurred the next morning and the ipsilateral ICA was occluded with detachable balloons. Spasm of the ICA was observed in most of the patients after stent placement; however, angioplasty was not required. Symptoms improved in all patients after treatment, without thromboembolic events. Follow-up cerebral angiography showed complete exclusion of all DCCFs and stent patency without intrastent stenosis in the 8 patients who had successful deployment of the stent. Although a larger sample and expanded follow-up are needed, our series shows that covered stents can be used in the treatment of DCCFs with symptomatic relief.

Endovascular Techniques for Treatment of Carotid-Cavernous Fistula

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous communications in the cavernous sinus. Direct CCFs result from a tear in the intracavernous carotid artery. Indirect CCFs generally occur spontaneously and cause more subtle signs. Direct CCFs, which typically have high flow, usually present with ocular-orbital venous congestive features and cephalic bruit. Indirect CCFs, which typically have low flow, present with similar but more muted clinical features. Direct CCFs are always treated with endovascular methods. The goal is to occlude the fistula but preserve the patency of the internal carotid artery (ICA). Agents include detachable coils or liquid embolic agents delivered transarterially or transvenously. Arterial porous or covered stents are often used adjunctively. In rare cases, the ICA must be occluded. Indirect CCFs are only treated if symptoms are intractable or intolerable or if vision is threatened. The goal is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus. The traditional approach has been transarterial embolization with liquid agents, particularly n-butyl cyanoacrylate (n-BCA). However, the multiplicity of arterial feeders and the low success rate in occluding indirect CCFs by the arterial route has led to a preference for transvenous embolization, most commonly via the inferior petrosal sinus. If that sinus is impassable, alternative routes include the pterygoid venous plexus, superior petrosal sinus, facial vein, or ophthalmic veins. The cavernous sinus is occluded with coils, liquid embolic agents, or both. The use of ethylene vinyl alcohol copolymer (Onyx), an agent that may be superior to n-BCA because it may allow better distal fistula penetration. However, more safety and efficacy data must be accumulated. When experienced interventionalists are involved, the success rate for closing direct fistulas is 85%-99% and for closing indirect fistulas is 70%-78%. Serious complications are relatively infrequent.

Direct Carotid-Cavernous Fistula Causing Brainstem Venous Congestion

A 39-year-old man who presented with unilateral proptosis and periocular pain rapidly developed reduced consciousness, facial numbness, dysarthria, and gait ataxia from a direct carotid-cavernous fistula (CCF) with drainage into posterior fossa veins. Brain MRI revealed abnormal signal throughout the brainstem, indicative of venous hypertension and edema. Closure of the fistula by detachable balloon eliminated the clinical and imaging abnormalities. This is the fifth reported case of brainstem complications of a direct CCF. It highlights potentially serious complications of this condition and their reversibility with prompt treatment.

Usefulness of Intravascular Ultrasonography Monitoring of Coil Embolization for Traumatic Direct Carotid-Cavernous Fistula -Case Report-

A 61-year-old woman was admitted for head injury after a traffic accident. Two months later, she developed abducens nerve palsy, chemosis, and pulsatile tinnitus. Right internal carotid angiography demonstrated a high flow direct carotid-cavernous fistula (CCF) at the C(5) portion with reflux into the superficial and deep sylvian veins, superior ophthalmic vein, superior petrosal sinus, and inferior petrosal sinus. Intravascular ultrasonography (IVUS) revealed a large fistula at the C(5) portion of the internal carotid artery (ICA). Coil embolization via transarterial and transvenous approaches under IVUS monitoring was performed. During the procedure, IVUS accurately detected protrusion of a coil into the parent ICA, and the parent artery could be preserved. IVUS monitoring is useful for embolization of direct CCF with coils.

Intracranial Pseudoaneurysms, Fusiform Aneurysms and Carotid-Cavernous Fistulas

The study assessed the effectiveness and safety of endovascular covered stents in the management of intracranial pseudoaneurysms, fusiform aneurysms and direct carotid-cavernous fistulas. Fourteen endovascular covered stents were used to repair three pseudoaneurysms, six fusiform aneurysms and six direct carotid-cavernous fistulas. Aneurysms were in the carotid artery in seven cases, in the vertebral artery two cases. It was not possible to treat two additional cases transcutaneously for technical reasons (2/15). Percutaneous closure of the lesions with an endovascular covered stent was successful in 13 of 15 cases. Initial follow-up showed good stent patency. No complications were observed after stent implantation. During follow-up, stent thromboses were detected in two of nine patients with follow-up digital subtracted angiography. One carotid-cavernous fistula of Barrow Type A transformed into Barrow Type D at nine month follow-up study was cured with a procudure of Onyx-18 injection. Endovascular covered stents may be an option for percutaneous closure of intracranial pseudoaneurysms, fusiform aneurysms and direct carotid-cavernous fistulas. Endoluminal vascular repair with covered stents offers an alternative therapeutic approach to conventional modalities.

Transarterial Embolization of Direct Carotid Cavernous Fistulas with the Double-Balloon Technique

Treatment of direct carotid cavernous fistulas (CCF) has progressed from surgical ligation to surgical trapping to endovascular techniques. Endovascular therapies are advantageous as they allow for occlusion of the fistula whilst preserving flow in the parent carotid artery. However, technical difficulties are not uncommon and occur when the fistulous orifice is too small or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Both circumstances may lead to technical failure or an unplanned sacrifice of the parent internal carotid artery (ICA). Here we describe a double-balloon technique used in the embolization of CCF in four patients that were successfully treated with complete immediate occlusion whilst preserving the parent ICA.

Endovascular Treatment of a High-Flow Direct Traumatic Carotid Cavernous Fistula with a Two Year Follow-up.

Endovascular treatment of high-flow direct traumatic carotid cavernous fistula (CCF) carries many difficulties. One of them is that carotid dissection may be associated with pseudo- aneurysm formation even when the CCF can be successfully embolized by detachable balloons. This article details a unique technique of treating pseudo-aneurysm by obstructing the lumen with preservation of the parent artery. The case presented here involves a 50-yearold man with a history of severe trauma. The angiography revealed that his bilateral highflow carotid cavernous fistula was successfully embolized by detachable balloons and control digital subtraction angiography at the end of the procedure demonstrated the fistula closed and the internal carotid artery preserved. But two months later, a pseudo-aneurysm formed in the right internal carotid artery. Under endovascular treatment along with other techniques including coils, stent-assisted and covered stent, the pseudo-aneurysm was excluded with preserved ICA. Two years later, the fistula and pseudo-aneurysm both disappeared quietly without patent foreign body reaction in the parent arterial wall.

Diagnosis and endovascular treatment of spontaneous direct carotid-cavernous fistula

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. We retrospectively analyzed the clinical data of nine patients with spontaneous direct CCF admitted between May 2003 and November 2007 and the outcomesof 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. 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. 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.

STENT GRAFT TREATMENT OF CEREBROVASCULAR WALL DEFECTS

Endovascular stent graft (SG) deployment offers a useful vessel-preserving strategy for vascular wall lesions such as pseudoaneurysms and fistulae. Although deployment of expanded polytetrafluoro-ethylene-covered SGs within the carotid and vertebral arteries is technically feasible, data on long-term efficacy, safety, and patency rate remain sparse. Six patients with traumatic (n = 4), iatrogenic (n = 1), or spontaneous (n = 1) internal carotid and vertebral artery injuries (direct carotid-cavernous fistula, n = 2; pseudoaneurysms, n = 4) were treated with nine balloon-mounted coronary expanded polytetrafluoro-ethylene SGs. Angiographic (mean, 2.3 yr; range, 1.7-4.2 yr) and neurological follow-up (mean, 2.7 yr) was performed for all patients. Complete angiographic exclusion of the lesion was achieved by the initial procedure in five of the six patients; one ruptured cavernous carotid aneurysm leading to a direct carotid-cavernous fistula showed persistent slow shunting despite tandem deployment of two SGs. All six patients revealed complete and persistent angiographic obliteration at delayed follow-up, with minimal in-stent stenosis (<20%) seen in two instances. Difficulty with SG navigation was encountered in five patients, resulting in one instance of guide catheter-induced intimal dissection. Type I endoleak was observed in five patients, requiring secondary angioplasty in four patients and deployment of an additional tandem SG in three. Technical challenges in current-generation SG deployment include sizing, navigation, positioning, and propensity for endoleak. When managed successfully, stent grafting provides a valuable approach for the treatment of vascular wall defects for which vessel preservation is preferred. Intermediate-term safety is satisfactory, with no delayed complications and minimal in-stent stenosis in follow-up periods of more than 2 years.

Endovascular Treatment for Type A Carotid Cavernous Fistulas with Detachable Coils

Objective: Carotid cavernous fistulae (CCF) after head traumas are abnormal communications between the internal carotid artery and venous compartments of the cavernous sinus. Fistulae are uncommon but well-documented sequelae of craniofacial trauma. We report our experiences in placing detachable coils in the management of rare cases of direct CCF after head injuries. Methods: From January 2002 to December 2007, nine patients were admitted and treated for traumatic direct CCF at our hospital. The medical records and neuroimaging studies were retrospectively reviewed. Results: All 9 patients had previous head trauma histories and ocular symptoms including exophthalmos, conjunctiva injection, and chemosis. Angiography was performed to confirm the CCF and for treatment planning. According to the angiograph, three patients had pseudo-aneurysms. All of the patients were treated with detachable coils via the trans-arterial endovascular maneuver. Among them, two patients had recurrences, the first at postoperative day one and the other eleven days after the surgery. Both recurrences were retreated endovascularly. All nine patients were successfully treated anigographically by means of trans-arterial embolization and improved symptomatically within a week. Conclusion: The etiology of CCF, especially type A, is well known. Also, the advances in interventional neuroradiology and cranial base surgery are chiefly responsible for the evolution of treatment strategies for CCF. Although other techniques and approaches with other materials may be useful, embolization with detachable coiling, as used in our cases, can be a safe and effective method to occlude the fistula and to improve symptoms. (J Kor Neurotraumatol Soc 2008;4:77-83)

Unilateral Vision Impairment From a Carotid-Cavernous Fistula After a Monobloc Osteotomy in a Patient With Apert Syndrome

A patient with Apert syndrome who underwent a monobloc osteotomy with distraction advancement sustained partial unilateral vision loss as a complication from a direct carotid-cavernous fistula. Successful embolization was used to treat the fistula. Precaution should be taken by craniofacial surgeons in performing similar procedures in patients with Apert syndrome because of their unique skull abnormalities.

Combined transarterial N-butyl cyanoacrylate and coil embolization of direct carotid–cavernous fistulas

The authors report two cases of traumatic carotid-cavernous fistulas treated successfully with combined N-butyl cyanoacrylate glue and coil embolization via a transarterial approach. In both cases complete occlusion of the fistula was achieved, with preservation of the parent carotid artery. Casting of the cavernous sinus with a liquid embolic agent was well tolerated and produced no complications of cranial nerve palsy. This technique provides interventionalists with yet another treatment option in these often complex cases.

Magnetic resonance angiographic demonstration of carotid-cavernous fistula using elliptical centric time resolved imaging of contrast kinetics (EC-TRICKS)

Magnetic resonance angiographic evaluation of the intracranial vasculature has been predominantly carried out using conventional angiographic techniques such as time of flight and phase contrast sequences. These techniques have good spatial resolution but lack temporal resolution. Newer faster angiographic techniques have been developed to circumvent this limitation. Elliptical centric time-resolved imaging of contrast kinetics (EC-TRICKS) is one such technique which has combined the use of elliptical centric ordering of the k-space with multiphase 3D digital subtraction MR angiogram (MRA) to achieve excellent temporal resolution of the arterial and venous circulations. Its applications have been mainly in the peripheral vasculature. We report the use of this technique in a case of a high-flow, direct carotid-cavernous fistula to demonstrate its potential in intracranial MR angiography.

Result of Neck Clipping and Coil Embolization as a Treatment for Unruptured Aneurysm

The report of the International Subarachnoid Aneurysm Trial (ISAT) study showed that coil embolization was superior to neck clipping as a treatment for subarachnoid hemorrhage (SAH) (1). Recently, some results of treatments for unruptured aneurysm via coil embolization and neck clipping have been reported (2,3).We compared the results of coil embolization and neck clipping in our institute. Generally better outcomes were obtained by endovascular surgery than by neck clipping. Postoperative ischemic strokes occurred in one case (1.8%) as a major stroke and in three cases (5.6% ) as a minor stroke among coil-treated cases, and in two cases(2.6%) as a major stroke, and in seven cases(9.0%) as a minor stroke among neck clipping cases. Other complications after these treatments were six cases of subdural effusion/hematoma, four cases of infection, two cases of epidural hematoma, one abducens nerve palsy, one hydrocephalus, and one acute myocardial infarction among 78 neck clipping cases, and two subcutaneous hematoma, one pseudoaneurysm at the puncture points, one direct carotid-cavernous fistula among 54 coil-treated cases. Four coil-treated cases, in which introduction of microcatheters to the aneurysm was impossible, were treated completely by neck clipping after endovascular treatments. In terms of modified Rankin Scale(mRS) three months after treatments, while mRS 3 was noted in only one case in the endovascular treatment group, there were one case of mRS 3, two cases of mRS 4, and two cases of mRS 5 in the neck clipping group. Duration of hospitalization averaged 11.9 days in the endovascular group and 24.1 days in the neck clipping group. The results of endosaccular enbolizations as treatment of the unruptured aneurysm seems to be better than neck clipping. However, not all cases of unruptured aneurysms can be treated by coil embolization due to the width of aneurysmal neck and relation of the aneurysm to parent arteries. Therefore, surgeons should also be able to perform neck clipping as an alternative modality.

Unusual Presentations of Skull Base Dural Cavernous Fistulae

Introduction: Direct carotid cavernous fistulae most commonly due to trauma are usually easy to diagnosis. Indirect fistulae, on the other hand, are often very difficult to diagnosis leading to substantial delay and potential significant visual system morbidity. Untreated dural fistulae lead to visual loss in 20 to 30% of patients. Untreated high cortical venous pressure contributes to morbidity by causing venous infarctions.