Controlateral cavernous syndrome, brainstem congestion and posterior fossa venous thrombosis with cerebellar hematoma related to a ruptured intracavernous carotid artery aneurysm

Intracavernous carotid artery aneurysms (ICCAs) are rarely associated with life-threatening complications. We describe a 55-year-old woman who, after the rupture of an intracavernous carotid artery aneurysm, presented with a contralateral cavernous sinus syndrome and severe posterior fossa and spinal cord symptoms. Following parent artery occlusion, thrombosis of the posterior fossa and spinal cord veins caused a progressive worsening of the neurological status to a "locked-in" state. The patient fully recovered with anticoagulation therapy. Comprehension of the pathophysiological mechanism associated with the rupture of ICCA and early diagnosis of the related symptoms are essential in order to plan a correct treatment that includes the management of the aneurysm rupture and of possible complications related to venous thrombosis.

Hypopituitarism caused by carotid cavernous fistula

Here we report a 79-year-old woman who presented with a 7-day history of headache, nausea, vomiting, and was found to have proptosis and ptosis. Laboratory findings showed hyponatremia, hypocortisolism, secondary hypothyroidism and low follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels. CT angiography (CTA) showed a vascular lesion in sella causing a mass affect on the pituitary gland which proved to be a carotid cavernous fistula (CCF) by conventional angiography. The lesion was subsequently treated with coil placement and patient's hyponatremia was successfully treated with corticosteroid and thyroid hormone replacement. Though rare, CCF should be considered in the differential diagnosis of sellar lesions. Also, in patients with CCF hyponatremia, hypotension or signs of hypothyroidism should warrant a work-up for pituitary function.

[The secret of red eyes]

"Red eye" is a sign and the same time a symptom frequently met in the ophthalmological practice. The "red eye" is not always the clinical manifestation of a common conjunctivitis. We will present a case report of a patient who accused conjunctival hyperemia, lacrimation, foreign--body sensation; she was also describing recurrent conjunctivitis for the past year. After an detailed ophthalmologic examination and interdisciplinary consultations. She was diagnosed with Basedow Disease and paraselar meningioma with invasion in the pterigoid fossa. The authors are suggesting that there is an indirect left carotid - cavernous fistula.

[Post-traumatic carotid cavernous fistula: report of two cases]

Carotid cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system. The authors reported the clinical presentation and therapeutic procedure of two cases. The physician has to be aware of this diagnosis when a patient is referred for a posttraumatic exophthalmia. The medical behaviour is multidisciplinary (ENT, ophthalmologist, radiologist and neurosurgeon). The imaging of choice is the angiography but angio-MRI and angio-CT can help to confirm the diagnosis. The endovascular embolization is the treatment of choice. It presents an acceptable risk of complication and a low risk of failure. In this paper the authors report 2 posttraumatic CCF cases treated with success by endovascular embolization.

[The diagnosis and treatment of traumatic pseudoaneurysm of internal carotid artery in sphenoid sinus (a report of 6 cases)]

OBJECTIVE

In order to prevent misdiagnosis and degrade death rate, we explored the early diagnosis and correct treatment methods of traumatic pseudoaneurysm of internal carotid artery in sphenoid sinus.

METHOD

The clinic data of 6 cases who had traumatic pseudoaneurysm of internal carotid artery in sphenoid sinus and were admitted in our hospital were analyzed retrospectively. Large numbers of literature about the disease were reviewed. Some early diagnosis methods and optimal treatment schemes were proposed.

RESULT

All patients had a history of cranium trauma and recurrent attacks nasal hemorrhage. There are two patients with a complication of sight loss in single eye. In the six cases, one case was treated with unilateral common carotid artery ligation, three cases were treated with aneurysm and internal carotid artery embolism by using sacculus proprius which is able to shedding, one case was treated with internal carotid artery embolism by using tiny circlip ring. These five patients were cured with no severe complication. One patient death of hemorrhage. His nasal cavity was tamponade repeatedly because repeat nasal hemorrhage. However, he had never treated with internal carotid artery embolism.

CONCLUSION

The patients who have traumatic pseudoaneurysm of internal carotid artery usually die of unmanageable hemorrhage. The patients may be cured if they could obtain an early diagnosis and correct treatment.

Emergency endovascular stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery

BACKGROUND

An internal carotid artery (ICA) injury is an uncommon but potentially fatal complication of transsphenoidal surgery.

CASE DESCRIPTION

We report a 61-year-old male patient with a right cavernous ICA injury sustained during transsphenoidal surgery and who underwent endovascular Stent graft placement. The ICA trapping was not indicated because of the absence of the left A1 on preoperative magnetic resonance angiography. During Stent graft placement, the ICA wall could not be completely fit with a stent due to its stiff nature and the carotid curve. The gap between the stent and the ICA wall was filled using a coiling procedure on the first postoperative day.

CONCLUSIONS

Endovascular Stent graft placement for posttranssphenoidal carotid artery injury is a useful technical adjunct to the management strategy and has the potential to minimize the risk of having to sacrifice the ICA. In cases of incomplete reconstruction of the Stent graft placement due to its stiff nature and the carotid curve, an additional coiling procedure could be helpful to obliterate the gap between the stent and the ICA wall. To avoid carotid injury during transsphenoidal surgery, careful preoperative evaluation of vascular structures and meticulous surgical technique are necessary.

Neuroimaging of traumatic brain injury

In this article, the neuroradiological evaluation of traumatic brain injury is reviewed. Different imaging strategies in the assessment of traumatic brain injury are initially discussed, and this is followed by a review of the imaging characteristics of both primary and secondary brain injuries. Computed tomography remains the modality of choice for the initial assessment of acute head injury because it is fast, widely available, and highly accurate in the detection of skull fractures and acute intracranial hemorrhage. Magnetic resonance imaging is recommended for patients with acute traumatic brain injury when the neurological findings are unexplained by computed tomography. Magnetic resonance imaging is also the modality of choice for the evaluation of subacute or chronic traumatic brain injury. Mild traumatic brain injury continues to be difficult to diagnose with current imaging technology. Advanced magnetic resonance techniques, such as diffusion-weighted imaging, magnetic resonance spectroscopy, and magnetization transfer imaging, can improve the identification of traumatic brain injury, especially in the case of mild traumatic brain injury. Further research is needed for other advanced imaging methods such as magnetic source imaging, single photon emission tomography, and positron emission tomography.

[Direct carotid-cavernous fistulas: clinical presentation, angioarchitectonics and endovascular management]

Since 1992 till 2007 233 male and 125 female patients (total--358) with direct carotid-cavernous fistulas (CCF) were operated. Mean age was 36.3 years. 88.5% of all cases were traumatic, 10.6% spontaneous, 0.3% congenital and 0.6% iatrogenic. CCF occlusion was performed via arterial, venous and combined endovascular approaches using balloon-catheters, coils and stents. Reconstructive surgeries were made in 78.7% of patients, deconstructive--in 21, Share of reconstructive operations has grown by 18.7% compared to the previous decade and succeeded 89.5% during recent 5 years due to development of modern endovascular techniques (balloon- and stent-assistance, venous approach). Recurrent fistulas after transarterial balloon occlusion was encountered in 10.3% of patients and were caused by decrease of volume or migration of balloon, which required additional intervention. Complete occlusion was achieved in 92.3% of cases, subtotal in 3.6%, partial in 4.1%. Two groups of patients treated with detachable balloon-catheters designed by prof. F.A. Serbinenko (DBC) and valve balloon-catheters (VBC) were analyzed. In the VBC group recurrent CCF were observed 1.5 time higher, but incomplete occlusion of the fistula and occlusion of ICA was observed 2 and 2.4 times, respectively, rarer than in DBC group. Early clinical outcomes were evaluated within 1-4 weeks; by date of discharge full recovery was achieved in 3.6% of cases, improvement in 84.4%, no changes were revealed in 6.7%. 4.5% of patients produced persistent neurological deficit presented by deterioration in oculomotor function (3.1%) and consequences of ischemic processes in cerebral hemispheres (1.4%). Postoperative mortality was 0.84%. Consequences were commonly caused by formation of pseudoaneurysms of ICA in cavernous sinus and sphenoid sinus (10.3%). Infectious complications developed in 3 patients (0.84%). Transarterial endovascular occlusion is treatment of choice in management of CCF. Modern endovascular techniques allowed significant advances in effectiveness of endovascular treatment of CCF. The problem of development and treatment of pseudoaneurysms after balloon occlusion of CCF claims for separate detailed analysis.

Diagnosis and endovascular treatment of spontaneous direct carotid-cavernous fistula

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Carotid cavernous sinus fistula presenting with pulsating exophthalmos and secondary glaucoma

Carotid cavernous sinus fistula is abnormal communications between the carotid arterial system and the venous cavernous sinus. Carotid cavernous sinus fistula can develop either because of trauma or spontaneous causes. Spontaneous carotid cavernous sinus fistula is often associated with a pre-existing aneurysm in the intracavernous portion of internal carotid artery. However, these fistulas may be congenital arteriovenous connections that open spontaneously in the settings of collagen vascular disease, atherosclerosis, hypertension, or may develop in females during peripartum period. A case of spontaneous carotid cavernous sinus fistula in a young adult male who presented with pulsating exophthalmos and secondary glaucoma is presented. Characteristic features of arteriovenous fistula--bruit, thrill, corkscrew episcleral vessels were present. Radiological investigations were done to confirm the diagnosis. Transvenous embolisation was done to close the fistula.

Marginal sinus arteriovenous fistulas mimicking carotid cavernous fistulas: diagnostic and therapeutic considerations

Marginal sinus fistulas (MSFs) are uncommon vascular anomalies. Occasionally, the dominant venous drainage is forced retrograde up the inferior petrosal sinus and into the cavernous sinus, causing chemosis, proptosis, and ocular hypertension, mimicking a carotid cavernous fistula. This atypical clinical presentation may lead to misdiagnosis and inappropriate hazardous treatment of an MSF. Identifying the site of the fistula and understanding the anatomy of the venous drainage are critical in providing appropriate, safe, and efficacious endovascular treatment.

[Diagnostic difficulties in differentiating of arteriovenous fistula -- case report]

Arteriovenous carotid-cavernous fistula is an abnormal connection between the dural branches of carotid artery or vertebral artery and the dural sinuses. Its clinical manifestations can resemble the crucial signs of thyroid orbitopathy, an inflammatory disorder of the orbit associated with Graves' disease. Therefore, differential diagnosis of thyroid orbitopathy and the congestion of the orbit seen in arteriovenous fistula is often clinically and radiologically confused. This is the case report of the simultaneous occurrence of dural arteriovenous fistula in 59 years old woman. The first manifestation was unilateral exophthalmia. After Computer Tomography and Magnetic Resonance Imaging were performed, the preliminary diagnosis of thyroid orbitopathy was established. The response of eye disorder to corticosteroid treatment resulted in evident deterioration. This prompted a reconsideration of the diagnosis and a new evaluation of the patient with sensitive techniques, leading to the final diagnosis of arteriovenous fistula.

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.

[Two cases of idiopathic carotid-cavernous fistula with headache and ophthalmoplegia]

We report two cases of idiopathic carotid-cavernous fistula (CCF) with primary symptoms of headache and diplopia. A 47-year-old woman presented with throbbing headache in her right frontal region followed by right trochlear nerve palsy. Brain magnetic resonance imaging (MRI) was normal but magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) revealed abnormal signals around the right cavernous sinus. CCF was diagnosed by conventional angiography. The symptoms improved naturally but after about 1 year she suddenly exhibited conjunctival congestion. A 41-year-old man complained of fluctuating headache with sudden left abducens nerve palsy. MRI and MRA were normal but CTA showed abnormal signals around the left cavernous sinus. A final diagnosis of CCF was made by conventional angiography and he was transferred to another hospital for stereotactic radiosurgery. Diagnosis of CCF tends to be delayed in cases presenting with only headache and external ophthalmoplegia. However, CCF with cortical vein drainage can lead to cerebral hemorrhage and early correct diagnosis is needed. Our cases showed a dilated superior ophthalmic vein in enhanced CT and an abnormal signal around the cavernous sinus in CTA. Therefore, CTA may be useful as a relatively non-invasive method that can provide diagnostic clues for CCF.

Diffuse large B-cell non-Hodgkin's lymphoma associated with bilateral carotid-cavernous fistulas in an elderly woman

A 74-year-old woman presented with a 2-month history of left proptosis, left eye chemosis, left abducens nerve palsy and cervical lymphadenopathy. She was noted to have bilateral carotid cavernous fistulas and was treated with transvenous coil embolization. The diagnosis of diffuse large B-cell non-Hodgkin's lymphoma was only confirmed 4 months later, despite a high index of suspicion, after clinical deterioration. This is, to our knowledge the first reported case of non-Hodgkin's lymphoma associated with bilateral carotid cavernous fistulas.

Massive exophthalmos after traumatic carotid-cavernous fistula embolization

An 18-year-old man without previous clinical problems developed a left traumatic carotid-cavernous fistula after a traffic accident. An endovascular embolization with coils was performed without success. The drainage was derived to the superior ophthalmic vein solely and clinical worsening occurred. Left eye proptosis, chemosis and intraocular pressure increased. Complete ophthalmoplegia developed and visual acuity decreased due to a central retinal vein obstruction. After a second embolization attempt the fistula was closed successfully but proptosis, chemosis and intraocular pressure remained uncontrolled despite medical treatment. Therefore an orbital decompression surgery was performed. Ophthalmoplegia, proptosis and chemosis improved and intraocular pressure was controlled. Although retinal hemorrhages persist, no neovascularization has developed. Central retinal vein occlusion in young patients seems to have a different etiology than in the elderly. In young patients, local factors are more frequently identified than systemic vascular diseases. Early detection of central retinal vein obstruction may prevent deterioration of visual acuity.

An uncommon cause of epistaxis: cartoid cavernous fistula

We report on an uncommon cause of epistaxis presenting to the emergency room. Epistaxis is not an uncommon presentation to emergency rooms across the world. The majority are easily controlled and have low mortality. We present a case of a carotid-cavernous fistula presenting with massive epistaxis culmination in cardiovascular collapse and death. Awareness of this entity will reduce the frequency of this condition resulting in major morbidity and mortality.

[Traumatic carotid-cavernous fistula]

Carotid-cavernous fistula is uncommon consequence of craniocerebral trauma. Earlier recognition of the patients with carotid-cavernous fistula and shorter time of delay in treatment could save patients from complications and vision loss. A 27-year-old man presented with severe craniocerebral injury after an car accident. He required emergent craniotomy for an open depressed cranial fractures, haemostasis and epidural hematoma. Three months later, the patient began to exhibit progressive chemosis and proptosis of left eye. Computed tomography and cerebral angiography revealed findings consistent with a carotid-cavernous fistula. Angiography revealed a fistula between carotid artery and the cavernous sinus. The patient was treated by transarterial embolization resulting in immediate and permanent occlusion of the fistula and improved visual acuity after six months follow-up. Posttraumatic carotid-cavernous fistula may be treated successfully with the use of transarterial coil embolization.

[Complex carotid cavernous sinus fistulas Barrow type D: endovascular treatment via the ophthalmic vein, imaging control with standardized MRI, long-term results]

PURPOSE

Since feeding arteries from both the internal and external carotid artery are common, cavernous fistulas of Barrow type D are difficult to treat. Embolization using the transarterial approach is considered to be the standard therapy. However, it is often impossible to embolize feeders from the internal carotid artery. The transorbital approach after anterior orbitotomy through the ophthalmic vein is an alternative in this complex situation. The following reports our experience with three female patients who underwent transvenous embolization. Procedural success was documented using standardized MRI and clinical reevaluation.

MATERIALS AND METHODS

Three female patients between 57 and 78 years of age were diagnosed with carotid cavernous fistulas by conventional angiogram. All patients were suffering from exophthalmus and visual impairment. Two patients showed secondary glaucoma and diplopia. In one patient we performed a technically successful transarterial embolization using particles, but no relevant improvement of the patient's condition was seen. Transfemoral transvenous access via the sinus petrosus was not possible in any patient. All patients were then embolized via the ophthalmic vein using GDC detachable coils. All patients were clinically reevaluated by an ophthalmologist. Also a standardized MRI was performed for documentation. Follow-up was performed for the first patient for 32 months, for the second patient for 34 months and for the third patient for 50 months.

RESULTS

Transvenous embolization was technically successful in all three cases. Clinical symptoms disappeared rapidly. Postprocedural MRI showed a symmetric diameter of the ophthalmic vein. Venous congestion of the orbit caused by fatty tissue edema regressed completely. Contrast-enhanced magnetic resonance angiography showed normal arterial vessels without evidence of fistula.

CONCLUSION

Complex carotid cavernous fistulas of Barrow type D seem to be successfully treatable by embolization using the transvenous approach. Clinical symptoms seem to regress rapidly after the procedure, with diplopia being the last to regress. MRI imaging criteria for procedural success include a diameter reduction of the ophthalmic vein, a reduction of the orbital fatty tissue edema and an inconspicuous CE-MRA.

Fístulas carótido-cavernosas. A propósito de dos casos

Carotid-cavernous fistulas are uncommon anomalous communications between the venous cavernous sinus and the carotid arterial system. We present two cases studied at our center. We show the characteristic CT, MRI, and orbital ultrasound findings and review the relevant literature.

A Migraine-Like Headache Induced by Carotid-Cavernous Fistula

Carotid-cavernous fistula (CCF) generally causes periorbital aching with ocular symptoms due to high venous pressure in the cavernous sinus, while migraine is caused by arterial dilatation-stimulating trigeminal nerves around the vessels. The authors present a case of 47-year-old woman with a 4-month history of a temporal throbbing headache. As her symptoms were well controlled by triptans, her headache was considered to be migraine in type. However, a Barrow's type-D CCF was revealed by radiological examinations. Self-compression of common carotid artery method was initially tried for therapy of the CCF, but endovascular embolization was finally necessary due to intractable headache. Although the headache was considered arterial in origin, transvenous embolization of the left cavernous sinus successfully ameliorated the patient's symptoms. CCF should be considered as an unusual etiology of headaches that appear arterial in origin.

Diagnosis and treatment of dural carotid-cavernous fistulas: a consecutive series of 27 patients

OBJECTIVES

To report clinical characteristics, angiographical findings and results of endovascular treatment of patients presenting with dural carotid-cavernous fistulas (DCCFs).

METHOD

Retrospective analysis of 27 consecutive patients with DCCF referred to a specialised interventional neuroradiology department.

RESULTS

Orbital and neuro-ophthalmological symptoms were the most common clinical presentation at diagnosis (n = 25). The venous drainage of the fistula involved the ipsilateral superior ophthalmic vein in 24 patients, the contralateral cavernous sinus in 6 and a leptomeningeal vein in 5 patients. Thrombosis of at least one petrosal sinus was found in 23 patients. 7 patients did not receive endovascular treatment: 3 had spontaneous DCCF obliteration, and 4 had only minor clinical symptoms and no leptomeningeal venous drainage on an angiogram. 20 patients received endovascular treatment via either a transvenous (n = 16) or a transarterial approach (n = 4). Complete occlusion of the fistula was obtained in 14 of 16 (87%) patients treated by the transvenous approach and in 1 of 4 (25%) patients treated by the transarterial approach. 16 patients had early clinical improvement after endovascular treatment. One patient had a cerebral haemorrhage after transvenous embolisation of a DCCF with leptomeningeal drainage. On follow-up, all patients treated by the transarterial route remained symptomatic, whereas 10 of 14 (71%) patients cured by the transvenous route were asymptomatic.

CONCLUSIONS

Transvenous embolisation is a safe and efficient endovascular approach to treat patients with DCCF. However, this technique requires a long learning curve.