Posttraumatic Carotid-cavernous Fistula Research Articles

Recurrent Post-Traumatic Carotid-Cavernous Fistula after Endovascular Treatment

Recurrent Post-Traumatic Carotid-Cavernous Fistula after Endovascular Treatment

Neglected Superior Ophthalmic Vein Enlargement Before Delayed Symptom of Carotid-Cavernous Fistula in a Blow-Out Fracture: A Case Report and Literature Review

Carotid-cavernous fistula (CCF) is rare condition. However, it should be suspected when there are traumatic facial fractures, because if not diagnosed, it can lead to permanent damage such as blindness. Traumatic CCF often presents delayed symptoms, and delayed diagnosis without prompt treatment can lead to permanent injuries in optic and cranial nerves III, IV, V, and VI as well as intracranial hemorrhage. The routine initial modality for patients with suspected facial bone fractures is non-contrast computed tomography (CT) to identify any fracture lines and check for intracranial hemorrhage. We report a post-traumatic CCF case with a 4-day symptom delay, where left superior ophthalmic vein enlargement was observed on the routine non-contrast facial CT with ipsilateral orbital wall fracture. When the patient first presented to the emergency room, we did not detect vein enlargement on CT. Afterwards, the patient developed delayed symptoms of CCF and was re-admitted to the emergency room. When we re-analyzed the first CT scan, an enlarged superior ophthalmic vein was confirmed. The diagnosis was confirmed via magnetic resonance imaging angiography, and the patient was successfully treated with embolization of the fistula. Thus, we recommend reviewing ophthalmic vein enlargement that is readily identifiable through non-contrast CT for patients injured by craniofacial trauma to suspect the presence of delayed CCF at their initial presentation.

An unusual complication of post-traumatic carotid-cavernous fistula

An unusual complication of post-traumatic carotid-cavernous fistula

Редкий случай развития каротидно-кавернозного соустья в офтальмологической практике

Purpose. Demonstration of a clinical case of the formation of carotid-cavernous fistula (CCF), which we observed in our ophthalmological practice. Material and methods. A 52-year-old patient who was urgently referred for surgical treatment of orbital phlegmon, accompanied by a decrease in vision to 0.02, reactive eyelid edema, secondary glaucoma, and rather mild exophthalmos of the left eye. On the same day, she was admitted to the hospital, where she underwent an opening and drainage of the orbit. However, after 5 days, against the background of further anti-inflammatory therapy, the patient began to be disturbed by a noise in the head, reminiscent of the «noise of a steam locomotive», and pain in the left eye appeared. Conducted selective computed tomography with angiography made it possible to establish the final diagnosis: cerebrovascular disease, arteriovenous malformation in the projection of the supraclinoid section of the left internal carotid artery, post-traumatic CCF on the left side. First, the patient underwent a course of vascular, decongestant, and symptomatic therapy, and then endovascular embolization CCF of the left side was successfully performed. Results. After that, headaches and noise in the head disappeared, exophthalmos and congestion in the form of edema of the eyelids and bulbar conjunctiva gradually regressed. However, the visual acuity of the left eye remained reduced (0.03) due to atrophy of the optic nerve. Conclusion. The rare occurrence of this pathology in ophthalmic practice may cause the lack of alertness of doctors of this specialty in terms of timely diagnosis of CCF. At the same time, it should be taken into account that neuroophthalmic symptoms are of decisive importance in clarifying the indications for the accelerated conduct of the only effective surgical endovascular treatment of this pathology. Particular care should be taken in cases where the patient has unilateral exophthalmos with a pulsating noise in the head and a history of blunt head trauma from several days to 2 months before their onset. Keywords: traumatic brain injury, carotid-cavernous fistula, diagnosis, carotid angiography, endovascular surgical treatment

Novel Treatment of Direct Carotid Cavernous Fistula with XCalibur Aneurysm Occlusion Device – A Case Report

To report a case of post-traumatic direct carotid-cavernous fistula (CCF) treated with Merlin’s XCalibur as a standalone treatment. XCalibur is a balloon mounted flow diverter covered with polymer biostable membrane. A single device was deployed across the rent which resulted in the complete exclusion of fistula. This is the second case of its kind to be reported for the treatment of post-traumatic direct CCF with an XCalibur device. The device proved to be effective and safe and did not require any additional coiling, thus this paper has immense value and benefit for the medical community at large as it displays a new technique being successfully used.

POST TRAUMATIC CAROTID CAVERNOUS FISTULA PRESENTING AS PARATHYROID CRISIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: This is a case of two rare entities causing non-specific symptoms. Carotid-cavernous sinus fistula (CCF) arises from miscommunication of carotid arterial flow and the cavernous sinus. Post traumatic CCF presents bilaterally are uncommon, only 1-2% of patients. While already a rare diagnosis, our patient presented in an acute parathyroid crisis defined by symptomatology caused by markedly elevated calcium and parathyroid hormone, which may have masked our diagnosis of CCF. CASE PRESENTATION: A 57-year-old Colombian female presented with dizziness, anorexia, nausea, and vomiting. She also endorsed intermittent diplopia in the left eye. Physical exam revealed left sided ptosis. She reports a remote history of head trauma a month prior. Serum calcium on presentation was 13.6 mg/dL, ionized calcium of 6.8 mg/dL, and parathyroid hormone (PTH) was 219.8 pg/mL. Subsequently, a Technetium 99m sestamibi scan showed increased radioisotope along the right lower pole of the thyroid gland confirming primary hyperparathyroidism. She was resuscitated with normal saline fluid and started on Cinacalcet for hypercalcemia. Attempts to lower serum calcium can be achieved using bisphosphonates and may be effective within the first 24 hours. In our patient, Cinacalcet did not achieve sufficient calcium lowering thus, Zoledronic acid was used due to its potency with small doses. Nausea, vomiting, and positional dizziness resolved. Despite resolution of symptoms, she continued with ptosis; thus prompting further work up. Magnetic resonance angiography and venography revealed extensive time of flight enhancement throughout the bilateral cavernous sinuses. A cervical and cerebral angiography revealed bilateral carotid cavernous fistulas with ophthalmic vein arterialization. The next day, she underwent left cavernous sinus embolization with coiling. Parathyroidectomy was delayed due to recurrence of ptosis and need for a second embolization for persistent diplopia that resulted in resolution of symptoms. DISCUSSION: Each of these diagnoses are rare and both require timely evaluation and treatment. The patient's symptoms are classically seen in a parathyroid crisis, with nausea, vomiting, and anorexia being the most common symptoms in up to 48% of parathyroid crises. Like the aforementioned, CCF symptomatology also includes non-specific symptoms; however, may pose more of a challenge during diagnosis as symptoms wax and wane depending on the hemodynamic flow within the fistula. CONCLUSIONS: This case highlights the necessity of a thorough physical exam and further as a reminder that a clinician must be vigilant in ruling out alternative pathologies supported by the objective findings no matter how rare or unlikely. REFERENCE #1: Churojana A, Chawalaparit O, Chiewwit P, Suthipongchai S. Spontaneous occlusion of a bilateral post traumatic carotid cavernous fistula. Interv Neuroradiol. 2001;7(3):245-252. doi:10.1177/159101990100700311 REFERENCE #2: Singh DN, Gupta SK, Kumari N, et al. Primary hyperparathyroidism presenting as hypercalcemic crisis: Twenty-year experience. Indian J Endocrinol Metab. 2015;19(1):100-105. doi:10.4103/2230-8210.131763 REFERENCE #3: Lowell AJ, Bushman NM, Wang X, et al. Assessing the risk of hypercalcemic crisis in patients with primary hyperparathyroidism. J Surg Res. 2017;217:252-257. doi:10.1016/j.jss.2017.06.041 DISCLOSURES: No relevant relationships by Roman Bernstein, source=Web Response No relevant relationships by Ariol Labrada, source=Web Response No relevant relationships by Tram Nguyen, source=Web Response No relevant relationships by Elena Tellez, source=Web Response No relevant relationships by Yaswanraj Yuvaraj, source=Web Response

Post-traumatic carotid–cavernous fistula

A 46-year-old man attended the emergency department with a 24-hour history of sudden onset and progressive proptosis of the left eye. Over the previous days, he had experienced severe nausea...

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.

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.

Posttraumatic cerebrovascular injuries in children. A systematic review.

Posttraumatic craniocervical vascular injuries in pediatric traumatic brain injury (TBI) are rare, and children-specific, evidence-based standards on screening and therapy of posttraumatic carotid-cavernous fistula (CCF), craniocervical artery dissections (CCAD), traumatic aneurysms (TA), and posttraumatic sinus venous thrombosis (SVT) is lacking. The aim of this review is to summarize the data on epidemiology, clinical presentation, and treatment of these traumatic lesions in a systematic manner. We performed a systematic PubMed search for records of CCF, CCAD, TA, and SVT related to pediatric TBI published until June 2019. After screening 2439 records, 42 were included in the quantitative analysis. Incidences for CCAD in blunt TBI were 0.21% (range 0.02-6.82%). 11.7% (range 1.69-15.58%) of pediatric aneurysms were found to be traumatic of origin, whereas 38.2% (range 36.84-40%) of all pediatric SVT were due to blunt TBI. For all of the posttraumatic cerebrovascular pathologies, we found a clear male predominance with 68.75% in CCF, 63.4% in CCAD, 60% in TA, and 58.33% in SVT. Clinical presentation did not differ from the adult population with exception of young child. While there is only recommendation for the therapy of CCAD and SVT in the pediatric population, no such recommendation exists for the treatment of CCF's and TA's, and data from randomized controlled trials is lacking. While these results show that posttraumatic CCF, CCAD, TA, and SVT are rarely encountered in children, misdiagnosis may have potentially drastic consequences due to a longer lifetime burden in the pediatric population. Awareness, early recognition, and prompt initiation of the appropriate therapy are essential to avoid morbidity and mortality. Further studies should focus on the development of clinical and radiological screening criteria of posttraumatic vascular lesions in children.

Post-traumatic right carotid-cavernous fistula resulting in symptoms in the contralateral eye: a case report and literature review

BackgroundTo report a case of a carotid-cavernous fistula (CCF) that occurred after a motor vehicle accident and review the uniqueness of this case and the main confusing points for the diagnosis of such cases.Case presentationA 22-year-old man complained of left eyelid swelling, eye redness, visual decrease and occasional headache after motor vehicle accident 4 months prior during which he experienced a head injury. He was initially thought to have glaucoma, but he was finally diagnosed with a right CCF based on magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). Timely embolization surgery resulted in obvious relief of the ocular symptoms and an improved prognosis.ConclusionThis is the first reported case of a post-traumatic unilateral CCF with contralateral symptoms in direct CCF, it is very infrequent and deserves our attention. We should maintain high suspicion of CCF and confirm the diagnosis by DSA when managing such patients to prevent serious consequences. Early diagnosis and treatment can improve the prognosis of patients.

Treatment of post-traumatic carotid–cavernous fistulas using pipeline embolization device assistance

This report describes two cases of post-traumatic, high flow carotid–cavernous fistulas that demonstrated residual shunting after initial embolization with coils and Onyx, and that were successfully closed with pipeline embolization...

Posttraumatic Carotid Cavernous Fistula that Presented as Seizure and Focal Neurological Deficits with Symptom Resolution after Therapeutic Coil Embolization

BackgroundA posttraumatic carotid cavernous fistula can remain unrecognized and ultimately present with symptoms characteristic for a middle cerebral artery stroke. Progressive neurologic deterioration can occur until the condition is diagnosed and treated. If unrecognized and untreated, permanent damage may result. Case ReportA 46-year-old white man with the history of a motor vehicle crash 6 months prior presented with complaints of acute onset of expressive aphasia and seizure-like activity for 3 days. On presentation, the patient was noted to have moderate proptosis and chemosis of the left eye. Magnetic resonance imaging of the brain showed an arteriovenous fistula arising from the anterolateral precavernous left internal carotid artery. This was directly communicating with the adjacent cortical veins along the medial aspect of the left temporal lobe, resulting in venous congestion in the left frontal opercular region, the left insula, and subinsular tracks. The patient underwent an intracranial coil embolization of a left carotid cavernous fistula. No complications were encountered, and the patient had near-complete resolution of neurologic deficits and left eye proptosis. Why Should an Emergency Physician Be Aware of This?Although posttraumatic carotid cavernous fistula is a rare condition, it is important to be aware of this entity because immediate diagnosis and treatment may improve outcome.

Direct Post-traumatic Carotid Cavernous Fistula Treated by Endovascular Intervention

The Carotid-Cavernous Direct Fistula (CCF) is a high-flow injury resulting from the wall laceration of the cavernous segment of the internal carotid artery and its subsequent communication with the cavernous sinus [1]. The vast majority of direct CCF is traumatic but direct posttraumatic CCF represents a rare entity, occurring in only 0.17 to 1.01% of all Traumatic Brain Injury (TBI) [1,2]. Clinical presentation may involve impairment of cranial nerves III, IV, V and VI, causing paralysis on the extrinsic eye movement and diplopia, besides the emergence of headache, retro-orbital pain, chemosis and proptosis and even intracranial hemorrhage [2].

Opis przypadu Późna manifestacja pourazowej przetoki szyjno-jamistej –

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Roskal-Wałek J, Biskup M. Post-traumatic carotid cavernous fistula of late manifestation report. Medical Studies/Studia Medyczne. 2014;30(4):265-270. doi:10.5114/ms.2014.47926. APA Roskal-Wałek, J., & Biskup, M. (2014). Post-traumatic carotid cavernous fistula of late manifestation report. Medical Studies/Studia Medyczne, 30(4), 265-270. https://doi.org/10.5114/ms.2014.47926 Chicago Roskal-Wałek, Joanna, and Michał Biskup. 2014. "Post-traumatic carotid cavernous fistula of late manifestation report". Medical Studies/Studia Medyczne 30 (4): 265-270. doi:10.5114/ms.2014.47926. Harvard Roskal-Wałek, J., and Biskup, M. (2014). Post-traumatic carotid cavernous fistula of late manifestation report. Medical Studies/Studia Medyczne, 30(4), pp.265-270. https://doi.org/10.5114/ms.2014.47926 MLA Roskal-Wałek, Joanna et al. "Post-traumatic carotid cavernous fistula of late manifestation report." Medical Studies/Studia Medyczne, vol. 30, no. 4, 2014, pp. 265-270. doi:10.5114/ms.2014.47926. Vancouver Roskal-Wałek J, Biskup M. Post-traumatic carotid cavernous fistula of late manifestation report. Medical Studies/Studia Medyczne. 2014;30(4):265-270. doi:10.5114/ms.2014.47926.

Endovascular Treatment of Posttraumatic Carotid‐Cavernous Fistulas and Pseudoaneurysms with Covered Stents

The treatment of posttraumatic direct carotid-cavernous fistulas (TCCFs) with detachable balloons (DBs) is associated with relatively high recanalization rate. The aim of this study was to evaluate the feasibility of using covered stents in patients with posttraumatic carotid-cavernous fistulas (CCFs) and pseudoaneurysms. Twelve patients with posttraumatic CCFs and 3 with pseudoaneurysms following detachable balloon deployment referred for treatment with covered stents were enrolled into this prospective study. Data on technical success, initial and final angiography results, mortality, morbidity, and the final clinical outcome, were retrospectively collected and analyzed at 1-, 3-, 6-, 12-months, and then annually. The navigation and deployment of the covered stents to the target CCF were technically successful in 14 of the 15 attempted stents, giving a successful technical rate of 93.3%. Angiography poststent placement showed complete occlusion in 11 patients with 11 CCFs, and incomplete occlusion in 3. Follow-up angiography revealed complete occlusion and no obvious in-stent stenosis in any patient. Clinical follow-up demonstrated full recovery in 13 patients, and an unchanged status in 1. These preliminary results indicate that the use of a covered stent is a feasible procedure for the treatment CCFs and pseudoaneurysms.

Comparison of covered stents with detachable balloons for treatment of posttraumatic carotid-cavernous fistulas

Treatment of posttraumatic direct carotid-cavernous fistula (DCCF) with detachable balloons (DB) is associated with relatively low complete occlusion rates. We aimed to compare the angiographic and clinical results of treatment with covered stents with the results of treatment with DB. Thirty-four patients with posttraumatic DCCF were selected for treatment with DB (n=19, group A) or covered stents (n=15, group B). Data on the technical success, duration of initial procedure and hospital stay, initial and final angiographic results, mortality, morbidity and final clinical outcomes were collected and analyzed within 12months. DB deployment and covered stent placement were technically successful in all patients, except one patient in group B in whom the covered stent failed to navigate to the target DCCF. The initial angiographic results for the 33 patients with successful procedures showed complete occlusion in 16 patients in group A (84.2%; 95% confidence interval [CI]: 66%, 102%) and 11 patients in group B (78.6%; 95% CI: 54%, 103%; p>0.05). The 12-month angiographic results indicated complete occlusion in 12 patients in group A (63.2%; 95% CI: 39%, 87%) and 14 patients in group B (100%; p=0.013). The average initial procedure time was 120.0±17.76minutes in group A and 93.15±8.12minutes in group B (p<0.001). No significant differences were seen between the two groups in technical success, mortality, morbidity or final clinical outcomes. In this nonrandomized, prospective study of posttraumatic DCCF treatment, the 12-month angiographic results of treatment with covered stents was superior to that of BD.

Traumatisme balistique occasionnant une fistule carotido-caverneuse

Post-traumatic carotid-cavernous fistula is an abnormal communication between the internal carotid artery in its intracavernous portion and the cavernous sinus, resulting from a tear in the arterial wall connecting the internal carotid artery with the cavernous sinus. Direct gunshot trauma is unusual. Clinically, the symptoms most often include a classic triad: red eye, chemosis and proptosis. Cross-sectional imaging including CT angiography allows for positive diagnosis by showing pathognomonic signs. Arteriography remains the procedure of choice for proper mapping of the lesion and accurate specification of the type of fistula, and at the same time serves as a means of embolization.

Angioarchitecture and Treatment Modalities in Posttraumatic Carotid Cavernous Fistulae

Posttraumatic carotid cavernous fistulae are abnormal direct hole communications between the intracavernous carotid artery and the cavernous sinus that can result from both blunt and penetrating trauma. They can be challenging lesions to treat and a variety of modalities and approaches have been proposed since endovascular treatment has become the standard treatment. An analysis of the angioarchitecture of 32 consecutive patients treated in our service demonstrated that seven could be classified as small hole, eight medium and 17 large. Different size fistulae required varying endovascular tools. Small fistulae were best treated using coils and large and medium lesions with balloons. Large lesions were more likely to require multiple tools in order to achieve closure and had a lower chance of ipsilateral carotid preservation. All patients in the series were cured with a carotid preservation rate of 66%. There was no permanent morbidity associated with endovascular treatment.

Treatment of Post-Traumatic Carotid-Cavernous Fistulas with the Willis Covered Stent

We describe our preliminary experience on the feasibility of using the Willis covered stent in patients with carotid-cavernous fistulas (CCFs). Eleven consecutive patients with post-traumatic CCFs referred for treatment with Willis covered stents were enrolled into this prospective study, and were subsequently followed-up at our hospital. Data on technical success, initial and final angiographic results, mortality, morbidity and final clinical outcome, was collected, with follow-up performed at one, three, six and 12 months, and yearly thereafter. Deployment of the covered stents was technically successful in all patients. Angiographic results following stent placement showed a complete occlusion in eight patients with ten CCFs, and an incomplete occlusion in three. No adverse events occurred either during or after the procedure. Angiographic follow-up (mean 14.73 ± 6.77 months) revealed complete occlusion and no obvious in-stent stenosis in all patients. Clinical follow-up (mean 17.73 ± 6.48 months) demonstrated full recovery in ten patients, and improvement in one. These preliminary results indicate that the use of the Willis covered stent is a feasible procedure, and that it may therefore serve as an alternative treatment for CCFs. Longer follow-up assessments and an expanded clinical trial are needed.