Indirect internal carotid-cavernous fistula in infancy

A 4-month-old male infant with proptosis and episcleral injection initially thought to have orbital inflammation was found to have an indirect carotid-cavernous sinus fistula. He was treated conservatively without worsening of symptoms. The authors report the first case of indirect carotid-cavernous sinus fistula in an infant originating from the internal carotid artery.

Fistules carotido-caverneuses post-traumatiques à propos d’un cas et revue de la littérature

Les auteurs rapportent une observation clinique d'une fistule carotidocaverneuse survenue à la suite d'un traumatisme craniofaciale grave. Une exophtalmie unilatérale pulsatile et asymétrie des 2 sinus caverneux au scanner ont permis de suspecter le diagnostic. Une artériographie a permis de confirmer ce diagnostic, avec embolisation couronnée de succès chez ce malade, mais l’évolution est défavorable sur le plan neurologique avec apparition d'une HTIC réfractaire au traitement médical maximal. La fistule carotido-caverneuse est une complication rare mais grave pouvant engager le pronostic fonctionnel (cécité) et vital (hémorragie méningée et intracérébrale).L'artériographie et l'embolisation en un seul temps ont considérablement amélioré le pronostic.

Intrafistula pressure measurement in traumatic carotid cavernous fistulas--key to increasing safety and effectiveness of endovascular coiling

BACKGROUND

Very few diseases demostrate the tremendous variation and capricious results common with the clinical ensemble of carotid cavernous fistulas (CCFs). The treatment modality for CCFs has changed from surgical to endovascular therapy. Many options exist in endovascular therapy ranging from balloons to coils and liquid embolization agents like Onyx. This study was undertaken to assess the role of recording intra-fistula pressure (IFP) during endovascular coiling of CCFs in order to help us better understand the angiodynamics of the fistula and to make coiling safer and effective.

METHODS

IFP measurement was done in 15 cases of traumatic CCF undergoing endovascular coiling. Patients were prospectively analyzed by pre- and post- procedural clinical profile, degree of recovery and time until fistula occlusion. Univariate analysis was used to find the correlation between the reduction in IFP, the degree of fistula obliteration and time until occlusion.

RESULTS

Of the 15 patients who underwent endovascular coiling 13 had total occlusion of the fistula, 1 patient had subtotal occlusion and 1 patient had no occlusion of the fistula. There was 100 % internal carotid artery (ICA) patency. Univariate analysis showed a strong correlation between the degree of reduction in IFP and time required for fistula occlusion (p < 0.001). Patients with a significant drop in IFP were also preceived as having a higher chance of fistula occlusion after waiting 30 min.

CONCLUSION

To our knowledge this is the largest series in published literature focused on using only detachable coils as the first line embolizing agent in treatment of traumatic CCFs. We conclude that IFP monitoring will play an important role in making treatment of CCFs safer and more effective. The aim of coiling the fistula is not to tightly pack the fistula as during treatment of aneurysms; rather it is to reduce flow across the fistula leading to thrombosis thus reducing the requirement of coils.

[Diagnostic and therapeutic problems of bilateral carotid-cavernous sinus fistula]

Carotid-cavernous sinus fistula is an abnormal connection between the internal carotid artery, external one or their meningeal branches and the sinus cavernous. It can be the spontaneous or post-traumatic pathology. The main clinical syndrome is Dandy's triad: pulsating exophthalmia, chemosis, bruit in the region of orbit. These syndromes appear in the case of the most frequent direct carotid-cavernous sinus fistula (type-A in Barrow classification). Indirect carotid-cavernous sinus fistulas are significantly more uncommon and the symptoms can be atypical and less intensive. It makes difficulties in establishing the right diagnosis. The case report concerns the occurrence of bilateral carotid-cavernous sinus fistula, supplying by numerous arteries, with atypical clinical picture.

Ocular manifestations and the clinical course of carotid cavernous sinus fistulas in Asian patients

PURPOSE

To study the clinical course with regard to both the angiographic and visual outcomes of carotid cavernous fistulas (CCFs).

BACKGROUND

Carotid cavernous sinus fistulas (CCFs) are conditions which often present with ocular signs and symptoms. The clinical presentation of CCFs is varied according to the anatomy, haemodynamics and size of the CCF. CCFs causing significant symptoms or vision loss should be treated with embolization.

METHODS

This is a retrospective review of the medical records of all CCF cases seen in the Singapore National Eye Centre from September 2002 to December 2011.

RESULTS

45 patients who had confirmed CCF on conventional cerebral angiography were included. Anterior draining CCFs presented with orbital congestion while posterior draining CCFs presented with pain, diplopia and cranial nerve palsies. Mild residual symptoms were still present in 85% of treated direct CCFs despite complete angiographic closure however 52% of treated dural CCFs had complete resolution of symptoms despite only half of those achieving angiographic closure. Treated and untreated dural CCFs had similar outcomes (87% versus 76% recovered or improved (p > 0.05)). Poor outcomes can result from residual diplopia or vision loss from complications of the CCF itself (e.g. compressive optic neuropathy, glaucoma, retinopathy) or complications from CCF embolization treatment (e.g. central retinal artery occlusion).

CONCLUSION

Presenting symptoms and signs are related to the angiographic drainage of CCFs. Angiographic outcomes after embolization treatment may not always correlate with clinical outcomes.

The recovery time of traumatic carotid-cavernous fistula-induced oculomotor nerve paresis after endovascular treatment with detachable balloons

PURPOSE

The recovery time of traumatic carotid-cavernous fistula-induced oculomotor nerve paresis (ONP) after endovascular embolization with detachable balloons has not yet been adequately evaluated. This study was performed to make a deep analysis of the factors, which affect the prognosis of ONP after endovascular treatment of traumatic carotid-cavernous fistula (TCCF).

MATERIALS AND METHODS

We retrospectively evaluated the clinical characteristics and the outcome of oculomotor nerve function in a series of 98 consecutive patients with ONP due to traumatic carotid-cavernous fistula which were endovascular treated with detachable balloons. Univariate analysis was applied to test the association between the time of ONP recovery and clinical variables.

RESULTS

Ninety-eight consecutive patients (62 males, 36 females, mean age 34.2±12.7years) having presented with ONP underwent endovascular treatment with detachable balloons were enrolled in this study. ONP was complete in 22 (22.4%) patients and partial in 76 (77.6%) patients. Ninety (91.8%) patients were successfully occluded by single-session endovascular embolization. Retreatments by transarterial routes had to be performed in 8 (8.2%) patients because of recurrent fistula having occurred within 4weeks after embolization. ONP was recovered completely in all the patients, among who 4 (4.1%) were treated with occlusion of internal carotid artery. Factors showing significant association with the recovery time of ONP were the location of the fistula (P=0.007), the degree of preoperative ONP (P=0.003), the number of detachable balloon used (P=0.000) and the length of ONP before endovascular treatment (P=0.000).

CONCLUSION

Endovascular treatment of traumatic carotid-cavernous fistula-induced ONP with detachable balloons is a safe and effective method. The length of ONP before endovascular treatment, the location of the fistula, the degree of preoperative ONP, the number of detachable balloons used were the statistically significant predictors of the length of ONP complete recovery.

[Neuro-ophthalmology and interventional neuro-radiology--co-treatment for carotid cavernous sinus fistula]

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous communications in the cavernous sinus. In many cases of CCF's the primary signs are ocular manifestations, which include: pulsatile proptosis, orbital bruit, chemosis and conjunctival injection, elevated intraocular pressure, venous stasis retinopathy, and cranial nerve pareses. Patients in whom the fistula causes arterial drainage into the cerebral veins and sinuses are at risk for intracranial hemorrhage. The most common treatment for CCF's is endovascular occlusion of the lesion. The goal of this procedure is to occlude the fistula but preserve the patency of the internal carotid artery. The CCF itself, as well as its treatment, can be sight- and even life-threatening. We describe 3 case reports of patients with CCF, in order to demonstrate the cooperation between the neuro-opthalmologist and the invasive neuro-radiologist, in the follow-up of the patient and in the treatment timing decision.

[Unusual presentation of a carotid-cavernous fistula in Ehlers-Danlos type IV]

Carotid-cavernous fistulae may present clinically in different ways, depending on the diameter and flow of the artery involved. In a direct fistula between the internal carotid artery and the cavernous sinus (high - flow fistula) the clinical presentation is usualLy dramatic and the signs and symptoms are severe. Indirect fistulae, in contrast, result from the connection of branches of the internal carotid, external carotid, or both to the cavernous sinus (low - flow fistula) and often present in a moderate and/or indolent manner. Patients with Ehlers-Danlos type IV suffer from vascular wall fragility resulting in a high frequency of aneurysms, dissections and fistulae. We describe a patient with Ehlers-Danlos vascular type IV who presented with mild signs and symptoms, suggesting the existence of a low-flow fistula. After two weeks, the patient's condition rapidly deteriorated. Endovascular catheterization demonstrated direct carotid cavernous fistula which was successfully treated. This case demonstrates the importance of early consultation with an endo-vascular surgeon in every patient with Ehlers-Danlos suspected of harboring a carotid cavernous fistula.

Transarterial detachable coil embolization of direct carotid-cavernous fistula: immediate and long-term outcomes

BACKGROUND

Transarterial embolization is a standard method for management of direct carotid-cavernous fistula (DCCF). The purpose of this study was to report our experiences, and immediate and long-term outcomes of endovascular embolization of DCCFs by using detachable coils (DCs).

METHODS

Over 8 years, 24 patients with 25 DCCFs underwent endovascular DC embolization. There were 15 men and nine women; age ranged from 8 to 82 years (mean, 39 years). Immediate and long-term angiographic as well as clinical outcomes after endovascular DC embolization were retrospectively analyzed. The number and the length of DCs used to occlude the fistula were also evaluated.

RESULTS

Eighteen DCCFs were successfully occluded by single-session endovascular embolization with preservation of the parent artery. Retreatments by transvenous (n = 5) and/ or transorbital routes (n = 3) had to be performed in seven patients because of residual fistula (n = 4) or recurrent fistula (n = 4) occurring within 3 weeks after embolization. The average numbers and length of coils to occlude the fistulas were 14 (range, 2-31) and 189 cm (range, 16-756 cm), respectively. Four patients had small residual fistulas with spontaneous thrombosis on follow-up angiography. Three patients had transient cranial nerve impairment of the third (n = 1) or sixth (n = 2) nerve. There was no significant procedure-related neurological complication. The follow-up period was 3-48 months (mean, 19 months)

CONCLUSION

Endovascular DC embolization of DCCFs was proved both efficacious and safe in managing high-flow fistulas with sustained angiographic and clinical effects, particularly in those DCCFs with small fistula track and/or cavernous sinus. However, retreatment via various routes may be necessary in some patients because of residual or recurrent fistulas.

[A case of non-traumatic direct carotid-cavernous fistula presenting with cerebral infarction]

A 76-year-old female presented with a rare case of cerebral infarction as a complication of non-traumatic direct carotid-cavernous fistula (CCF). She had left hemiparesis and magnetic resonance imaging revealed cerebral infarction in the right watershed area. Angiography showed a right high-flow direct CCF with total blood steal. Preoperative 123I-IMP SPECT revealed a hypoperfusion area in the region of the right anterior cerebral artery and right middle cerebral artery. In addition, she had double vision caused by abducens nerve palsy. Transarterial embolization of the fistula with endovascular trapping using detachable coils achieved complete obliteration of the right internal carotid artery and adequate flow reduction of the direct CCF. Postoperative angiography showed good filling of the collateral-flow via the posterior communicating artery without retrograde blood steal to the CCF. Her symptoms improved gradually after the procedure. Diffusion-weighted MR imaging obtained 8 days after the procedure revealed a few high signals in the right hemisphere, suggesting cerebral infarctions, but she presented no symptom. Postoperative 123 I-IMP SPECT showed an improvement of cerebral perfusion in the region of the right MCA posterior and left MCA. Cerebral ischemia caused by direct CCF is rare, and there are only a few reports of non-traumatic direct CCF presenting with cerebral infarction. This very rare case suggests that endovascular trapping is safe and useful as a treatment for direct CCF, especially in the case of an elderly patient with total blood steal.

Use of onyx for transarterial balloon-assisted embolization of traumatic carotid cavernous fistulas: a report of 23 cases

BACKGROUND AND PURPOSE

TCCFs are a common complication following craniofacial trauma and are usually treated by coils or detachable balloons. The use of the liquid embolic agent Onyx as the sole agent for the treatment of TCCFs has been rarely reported. Herein, we summarized the preliminary experience and effectiveness of treating TCCFs with Onyx in 23 patients.

MATERIALS AND METHODS

From the 36 type A CCFs treated in our department between September 2005 and March 2011, a total of 23 posttraumatic direct CCFs were treated by using Onyx only via transarterial approach.

RESULTS

Immediate postprocedural angiograms demonstrated complete occlusion in all patients. All the patients underwent a single procedure except 1 with bilateral TCCFs. Up to 24-month clinical and 3-month angiographic follow-ups revealed an ongoing complete occlusion without any complications.

CONCLUSIONS

In this series, the use of Onyx for the transarterial embolization of TCCFs was feasible and effective. Associated adverse events were rare.

[Diagnosis and treatment of carotid-cavernous fistula: analysis of 28 patients]

OBJECTIVE

To evaluate the feasibility and efficacy of endovascular treatment for different types of carotid cavernous fistula (CCF) via the approach of internal carotid artery (ICA) or inferior petrosal sinus (IPS).

METHODS

From April 2005 to June 2010, 28 CCF patients underwent endovascular treatment at our institution. There were 13 males and 15 females with a mean age of 39 years (range: 21 - 71). According to the Barrow's classification, they were classified into type A (n = 21), type B (n = 2) and type D (n = 5). Patients of type A underwent detachable balloon embolization of ipsilateral cavernous sinus or stent-graft placement via the ICA approach. Patients of types B and D received detachable coil plus n-BCA (n-butyl-2-cyanoacrylate) embolization of ipsilateral cavernous sinus via the IPS approach. The technical results, complications and therapeutic outcomes were reviewed.

RESULTS

Detachable balloons (number: 1 - 4) were used in 16 patients of type A. Angiography at immediate postembolization showed a complete occlusion of fistula in 15 patients and a small residual fistula (< 20%) in 1 patient. Five patients of type A received stent-graft placement. One stent was placed in 4 patients and 2 stents in 1 patient. Complete fistula closures with preserved ICA were documented on immediate angiogram in 3 patients whereas a large residual flow (> 50%) persisted in 1. The fistula was completely occluded after 3 detachable balloons were deployed in affected cavernous sinus through a gap between stent and vascular wall. Both fistula and ICA were occluded in 1 patient after stenting. No cerebral infarction was observed due to the adequate collateral blood flow from contralateral ICA. Complete closures of affected cavernous sinus were achieved in 6 patients of types B and D while residual flow (< 50%) persisted in 1. The number of detachable coils for each embolization ranged from 3 to 8 (mean: 6.0). The volume of n-BCA mixture varied from 1.0 to 2.1 ml (mean: 1.3). The mean duration of n-BCA injection was 65 s (range: 45 - 90). Clinical symptoms were completely relieved in 26 patients. During the mean follow-up period of 30 months (range: 12 - 60), no recurrence of clinical symptoms was observed. No thrombosis or stenosis was found in the lumina of stents.

CONCLUSION

Detachable balloon embolization is the preferential treatment for direct CCF. Detachable coil plus n-BCA embolization of cavernous sinus via the IPS approach is an efficient and safe treatment for indirect CCF.

Isolated oculomotor nerve palsy in a white-eyed patient with dural carotid-cavernous sinus fistulas: a case report

The study reported a woman with dural carotid-cavernous sinus fistulas (CCFs) who presented with a unilateral white-eyed appearance, and painful oculomotor nerve palsy with pupillary involvement. After cerebral angiography, which revealed posterior drainage of the fistulas, the dural CCFs closed, the oculomotor nerve palsy subsided spontaneously and no recurrence occurred throughout the 2-year follow-up. Dural CCFs should be kept in mind when patients present with painful oculomotor nerve palsy. Moreover, cerebral angiography remains the standard diagnostic method and fistulas may close spontaneously following this procedure.

[Case of direct carotid-cavernous fistula presenting with subarachnoid hemorrhage]

We report a case of longstanding asymptomatic direct carotid-cavernous fistula (CCF) which caused fatal subarachnoid hemorrhage (SAH). A 91-year-old female with no history of previous head trauma and optic symptoms presented acute subarachnoid hemorrhage. Angiography revealed a left direct carotid-cavernous fistula draining only into the contralateral cavernous sinus with leptomeningeal venous reflux and small varix on the pontine bridging vein. The affected cavernous sinus was markedly dilated and there was no septum between the left cavernous sinus and the internal carotid artery. The patient underwent transvenous coil embolization for intercavernous sinus and leptomeningeal venous reflux was successfully obliterated and opacification of the varix was diminished. The past history of this patient and angiographical findings strongly suggest long standing asymptomatic CCF caused SAH.

[Embolization as a treatment method in traumatic bilateral direct carotid cavernous fistula]

A case of 42-year-old man with rare posttraumatic bilateral direct carotid. cavernous fistulas, who was three times treated by endovascular management via trans-arterial route with stent-assisted microcoil placement, is reported. Presented technique might be method of choice for the intervention in cases of bilateral traumatic ca. rotid-cavernous fistulas. Stent-as sisted microcoil placement may in crease ability to successfully treat fistulas with preservation of the parent artery.

[Embolization with cyanoacrylate glue as a treatment method in giant direct carotid cavernous fistula]

A case of 21-year-old woman with postraumatic giant direct carotid-cavernous fistula, successfully treated by endovascular embilisation with cyanoacrylate glue, is presented. Stent-assisted coils placement is the method of choice for the treatment of patients with carotid-cavernous fistulas, but closure of direct fistula with cyanoacrylate glue can be alternative, safety and efficient technique especially in cases in which standard interventions offer increased risk or in which other methods have failed.

Transvenous embolization of dural carotid cavernous fistula through the facial and ophthalmic vein

INTRODUCTION

Dural carotid cavernous fistula is acquired, relatively rare, condition comprising of numerous small-caliber meningeal arterial branches, draining directly into cavernous sinus. Endovascular therapy is the treatment of choice, preferably by a transvenous approach. In the case of inaccessible inferior petrosal sinus, other alternative routes are considered. We presented a case of dural carotid cavernous fistula completely occluded with Guglielmi detachable coils, using a transvenous approach through facial and superior ophthalmic vein.

CASE REPORT

A 62-year-old man was referred with a gradual worsening proptosis, red eye, and decreased visual acuity, on the right side. Digital subtraction an giography revealed the presence of a right dural carotid cavernous fistula, predominantly supplied from dural branches of the right internal carotid artery siphon, with minimal contribution from the right middle meningeal artery and contra lateral dural branches of the left internal carotid artery siphon. The fistula was drainaged through the dilated superior ophthalmic vein, and via the facial to the internal jugular vein. There was neither pacification of pterygoid and petrous sinuses, nor cortical venous reflux. Endovascular treatment was performed by a transvenous approach. A guiding catheter was placed in the right facial vein. A microcatheter was advanced through the dilated angular and superior ophthalmic vein, and its tip positioned into the right cavernous sinus. Coils were deployed, until a complete angiographic occlusion of the fistula had been achieved. The patient experienced rapid improvement in the symptoms, with complete normalization of his condition one month after the treatment.

CONCLUSION

Coil embolization of dural carotid cavernous fistula by transvenous catheterization, through the facial and superior ophthalmic vein, can be considered as safe and effective treatment option in the presence of marked anterior drainage.

Endovascular approach as primary treatment for traumatic carotid cavernous fistula: local experience from Pakistan

OBJECTIVE

To evaluate the technical success, complications and outcome of endovascular management of post traumatic carotid cavernous fistula (CCF) in patients presenting at a tertiary care hospital in Karahci.

METHODS

Descriptive case series of 26 patients of post traumatic CCF treated by endovascular techniques was carried out at Radiology and Neurosurgery departments of Aga Khan University hospital between January 2010 to March 2010. Medical records and radiology reports were retrospectively reviewed from November 2000 to December 2009. The diagnosis was primarily clinical and was confirmed in all cases by CT or MRI. Endovascular procedures were performed under general anaesthesia through femoral artery or femoral vein approach. Detachable balloons pushable coils and/or glue was used for fistula closure. Follow up was done via medical records and on phone. Technical success and safety of the procedure were analyzed and outcome in terms of symptomatic improvement was recorded wherever available.

RESULTS

Out of a total of 26 patients; 20 were male and 6 were female, with age range of 14 to 62 years, mean age 31.4 +/- 12.6 years. Technical success rate of endovascular embolization was 92.3% (24 out of 26 patients). Procedure could not be performed in 2 patients. In 20 out of 24 patients (83.3%) single session of embolization was performed while 4 patients required 2 sessions due to recurrence. In one of these patients the detachable balloon deflated after 2 hours of deployment and another session of embolization was immediately carried out by deploying a larger sized balloon. Complication rate was 15.3% (n = 4) one patient had infarction which recovered completely in 6 months. There was no procedure related mortality. Five patients were lost to follow up. In rest of the 19 patients follow up ranged from 1 to 14 months (Mean 11.0 +/- 11.8 months) 8 out of 19 (42.1%) patients showed complete resolution of symptoms and 9 (47.3%) reported improvement.

CONCLUSION

Endovascular approach is a safe and useful option for treatment of traumatic carotid cavernous fistula.

Delayed caroticocavernous fistula after stent-assisted coil embolization of intracavernous carotid aneurysm: should we manage conservatively?

Constructive endovascular techniques remain the mainstay for the treatment of cavernous carotid aneurysms due to their efficacy. However, they do harbor risks of complications, such as thromboembolic events, arterial injuries, and vessel occlusions. A 58-year-old lady presented with delayed caroticocavernous fistula (CCF) 1 month after stent-assisted coil embolization of a cavernous carotid aneurysm (CCA). Following this, her caroticocavernous fistula resolved spontaneously with no further intervention. Our case demonstrates a unique presentation of a CCF as a delayed complication of stent-assisted coil embolization of CCA and the spontaneous resolution of the CCF. Symptomatic CCFs are commonly treated as an emergency in many institutions and the question arises as to whether we should adopt a conservative policy in the light of this case report.

Diffusion restriction in thrombosed superior ophthalmic veins: two cases of diverse etiology and literature review

Thrombosis of superior ophthalmic veins (SOV) is a well known entity occurring secondary to varied etiologies. We describe diffusion restriction in thrombosed SOV in two cases of different etiologies- bilateral involvement in a patient with septic cavernous sinus thrombosis (CST) and another where embolisation of an indirect carotico-cavernous fistula (CCF) resulted in complete SOV thrombosis accompanied by clinical worsening. Our cases add to the limited literature on diffusion findings in SOV thrombosis.