[Successful treatment using detachable coils for traumatic carotid cavernous fistula as a complication of transsphenoidal surgery for a pituitary adenoma: a case report]

We report a case of a patient with traumatic carotid cavernous fistula (CCF) caused by transnasal-transsphenoidal surgery, who was successfully treated using detachable coils. A 47-year-old man was admitted to our hospital because of severe headache. He was confirmed to have a nonfunctioning pituitary adenoma with presellar-type sphenoid sinus. Cerebral angiography initially disclosed no vascular lesions. A transnasal-transsphenoidal adenomectomy was performed. When the anterior wall of the sphenoid sinus was dissected with a chisel, the chisel deeply stuck into the posterolateral part of the sinus. Profuse arterial bleeding was observed through the sphenoid sinus. The bleeding was stopped easily by compression and packing with bone wax. The operation was continued, the sellar floor was opened widely and the tumor was removed subtotally. The medial wall of the cavernous sinus was intact. Histological examination revealed a pituitary adenoma. Immediately after surgery, the patient noticed a bruit. He developed chemosis and abducent palsy on the right side. Cerebral angiography displayed a high-flow CCF, which was attributed to the carotid artery injury caused by the transnasal-transsphenoidal surgery. The CCF disappeared after two-staged embolization using detachable coils, 1st transvenous and 2nd transarterial. Ten months later, cerebral angiography showed persistent occlusion of the fistula, and the patient experienced no tumor recurrence. It is suggested that drilling is a safer procedure than using a chisel for dissection of a sphenoid sinus with incomplete pneumatization. Endovascular treatment using detachable coils proved useful to manage the CCF, an unusual complication of transsphenoidal surgery.

Transvenous embolization of carotid-cavernous sinus fistula associated with a primitive trigeminal artery--case report

A 58-year-old female presented with right conjunctival chemosis and right abducens nerve paresis. Cerebral angiography demonstrated a right carotid-cavernous sinus fistula associated with persistent primitive trigeminal artery. The fistula was treated by introducing detachable coils through the transvenous approach, as the detachable balloon was not available. Follow-up angiography performed 14 days after the embolization revealed complete disappearance of the carotid-cavernous sinus fistula due to thrombosis, which was presumably accelerated by the coils. Transvenous coil embolization should be considered as an alternative treatment for high-flow carotid-cavernous sinus fistula, but only if transarterial balloon embolization is not successful or unavailable.

Direct caroticocavernous fistula and traumatic dissection of the ipsilateral internal carotid artery: endovascular treatment

After severe craniocerebral trauma a 14-year-old boy developed progressive exophthalmos with venous congestion and chemosis, due to a direct caroticocavernous fistula. Angiography revealed traumatic occlusion of the ipsilateral internal carotid artery and absence of the inferior petrosal sinus. After failure of an approach via the anterior and posterior communicating arteries, the cavernous sinus was successfully catheterised through the occluded internal carotid artery, and embolisation performed with coils.

Carotid artery cavernous fistulas

The treatment of carotid cavernous fistulas has undergone a fundamental transformation during the preceding 30 years. Endovascular techniques have not only largely replaced surgical management of this disease, but have also resulted in substantially lower rates of procedure-associated morbidity and mortality. Percutaneous transarterial occlusion of direct cavernous carotid fistulas with preservation of the carotid artery using detachable balloons is now considered the current preferred therapeutic objective. Concurrent progress in percutaneous transvenous embolization techniques and materials has led to more effective and better-tailored therapies for indirect (dural) carotid cavernous fistulas. The current understanding of the clinicopathologic mechanisms associated with carotid cavernous fistulas and the endovascular therapies used in the contemporary management of this condition are reviewed.

[Refractory carotid-cavernous fistula: causes and countermeasures]

OBJECTIVE

To explore the causes and countermeasures of refractory carotid-cavernous fistula (CCF).

METHODS

Twelve refractory cases from 123 cases of consecutive traumatic CCF during 12 years were reviewed.

RESULTS

The main causes of refractory CCF were: small or large fistula's opening, or constrictive parent artery; inappropriate early treatments such as ligature of internal carotid artery or common carotid artery, balloon detachment of, and non-dense packing of coils inside the cavernous sinus; unexpected deflation or balloon displacement of resulting in fistula recurrence. Anatomical cure was achieved in 11 cases, and clinical care in 1 by using balloon or/and coil or/and NBCA (n-butal 2-cyanoacrylate) through arterial, venous or surgical approach.

CONCLUSIONS

refractory CCF can be treated effectively skilled catheterization and embolization as well as appropriate approach and embolic material according to fistula structure and vascular route.

[Dural arteriovenous fistula of the transverse sigmoid sinus after transvenous embolization of the carotid cavernous fistula]

We report a case of dural arteriovenous fistula of the transverse-sigmoid sinus after transvenous embolization of the carotid cavernous fistula. A 72-year-old woman presented with left exophthalmos, chemosis, bruit and left abducens nerve palsy in June 1996. Bilateral external and internal carotid angiograms revealed the dural arteriovenous fistula of the cavernous sinus. We embolized the dural arteriovenous fistula using a transvenous approach via the left inferior petrosal sinus. Angiograms demonstrated the complete disappearance of the dural arteriovenous fistula. Two years and six months later, she complained of tinnitus at the retroauricular region. Left external carotid angiograms showed a dural arteriovenous fistula of the transverse-sigmoid sinus fed by occipital, posterior auricular, middle meningeal and superficial temporal arteries. We embolized the dural arteriovenous fistula using a transarterial approach. Her symptoms disappeared but the dural arteriovenous fistula did not disappear completely. We discussed the clinical features and etiology of this case.

Endovascular arterial occlusion accomplished using microcoils deployed with and without proximal flow arrest: results in 19 patients

BACKGROUND AND PURPOSE

Prior to their relatively recent FDA approval, detachable balloons for endovascular arterial occlusion had been available on only a limited basis. We evaluated the feasibility of permanent endovascular carotid and vertebral artery occlusion using microcoils deployed with and without proximal flow arrest in 19 patients.

METHODS

Permanent endovascular occlusion was performed in 19 arteries of 19 patients. The treated lesions included nine aneurysms, one carotid-cavernous fistula/pseudoaneurysm, seven neoplasms, and two dissections. Nondetachable balloons were used to arrest proximal blood flow during occlusion of only six arteries. Anticoagulation (heparin, 5000 U IV) was used during occlusion of 18 arteries. Three to 88 coils were used per lesion. Complex fibered platinum microcoils were used for all cases, and GDCs were also used in two patients.

RESULTS

Sixteen patients had no new neurologic deficits after arterial occlusion. No patient had an acute event that suggested an embolic complication. Coils provided rapid and durable arterial occlusion in 17 patients. In both patients with acute carotid artery rupture, large numbers of coils placed during flow arrest failed to produce complete occlusion, which was accomplished subsequently with detachable balloons. One of these patients incurred a fatal hemispheric infarct after occlusion. One patient treated for a ruptured posterior inferior cerebellar artery aneurysm by vertebral artery occlusion continued to have progressive neurologic deficits. One patient with a cavernous aneurysm had upper extremity weakness and mild dysphasia 24 hours after internal carotid artery occlusion.

CONCLUSION

In our small series, microcoils were found to be safe and effective for neurovascular occlusion. When both intravenous heparin (5000 U IV bolus) and heparinized catheter flush solutions (5000 U/L) are used, flow arrest during coil placement is unnecessary to prevent clinically apparent embolic complications.

Management of a rare complication of endovascular treatment of direct carotid cavernous fistula

A 30-year-old woman with direct carotid cavernous fistula underwent endovascular treatment with detachable balloons via a transarterial route. The patient returned with diplopia 1 year after therapy. On cranial MR imaging, one of the balloons was detected in the proximal portion of the superior ophthalmic vein and was deflated percutaneously with a 22-gauge Chiba needle under CT guidance. The patient's symptoms resolved after balloon deflation. This case report presents a unique complication of endovascular treatment of direct carotid cavernous fistula and its management.

Direct carotid-cavernous sinus fistula due to ruptured intracavernous aneurysm treated with electrodetachable coils--case report

A 66-year-old female developed exophthalmos, impaired visual acuity (perception of light), and diplopia one day after sudden onset of headache. Neurological examination revealed proptosis, chemosis, impaired vision, and ophthalmoplegia. Carotid angiography showed direct carotid-cavernous sinus fistula concomitant with an intracavernous aneurysm on the right side. Intraaneurysmal embolization using the Guglielmi detachable coils (GDCs) via the transarterial route was performed and complete occlusion of the fistula successfully achieved. The neurological deficits resolved completely by 6 months after embolization. Intraaneurysmal GDC embolization via the transarterial route may be an alternative for the treatment of direct carotid-cavernous sinus fistula due to rupture of intracavernous aneurysm.

Carotico-cavernous fistula following septorhinoplasty

Septorhinoplasty is a very common operation in otolaryngological practice. We report the second case of a carotico-cavernous fistula following septorhinoplasty. This case presented with very severe epistaxis before the appearance of the typical pulsating exophthalmos, ophthalmoplegia, headache and engorged veins on the right side of the face. Our case was treated by endovascular thrombosis with electrolytically detachable coils.

Endovascular embolization of traumatic carotid cavernous fistulas

OBJECTIVE

To analyze the effectiveness of endovascular embolization on treatment of traumatic carotid-cavernous fistula (TCCF).

METHODS

From 1986 to 1997, 482 cases of traumatic carotid-cavernous fistula were treated by endovascular embolization in the Beijing Neurosurgical Institute. Several kinds of balloon-catheter were used for embolization. External carotid-cavernous fistulas and rare carotid-cavernous fistulas (CCF) with minute leakage were treated by cyanoacrylate or coils. Although artery approach was applied in most cases (477 cases), vein approach showed its own advantages in some special cases.

RESULTS

We found a special "bileakage sign" indicating multileakage of TCCF, which was never mentioned before. All 482 cases were embolized successfully, and 405 cases maintained the patency of internal carotid artery (ICA). No treatment-related deaths occurred and the symptoms and signs of 462 cases were relieved after embolization. Emergency embolization was needed in some conditions such as serious epistaxis, delayed or repeated subdural hematoma, and rapid visual impairment.

CONCLUSION

Endovascular embolization of TCCF is a safe and efficient method. Carefully selected operation time, operative approach, and materials are the essential factors to reach a best result.

[Digital subtraction angiography of cerebrum for diagnosis of cavernous sinus fistula and its intravascular treatment]

OBJECTIVE

To evaluate the diagnosis of digital subtraction angiography (DSA) of cerebral arteries and the intravascular treatment for carotid artery-cavernous sinus fistula (CCF) mainly manifesting as pulsating exophthalmos.

METHODS

Digital subtraction angiography (DSA) of cerebral arteries was carried out for 15 patients with pulsating exophthalmos. Of them, detectable balloon and tungsten filament microcoil were used for intravascular embolism treatment in 12 cases, and the 3 cases with CCF of the branch of external carotid artery were not treated.

RESULTS

Of the 15 cases, 12 were fallen in the CCF of high flow type of unilateral internal carotid artery, and 3 in the CCF of low flow type of unilateral external carotid artery. The symptoms and signs of intravascular embolism disappeared after treatment in 11 cases.

CONCLUSION

Cerebral artery DSA and intravascular therapy are the ideal methods for the diagnosis and treatment of CCF mainly manifesting as pulsating exophthalmos.