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.

[Pulse synchronous bruit, swollen eye, diplopia, exophthalmos, chemosis and diplopia three weeks after a head trauma]

Traumatic carotid-cavernous sinus fistulas represent an uncommon complication of a head trauma. The consequences of a delayed diagnosis are progressive ocular complications such as visual loss, extraocular muscle palsy, progressive proptosis, conjuctival chemosis, retinal vein occlusion and secondary glaucoma. Moreover, severe epistaxis, intracerebral and subarachnoidal hemorrhage may occur. We present a patient who developed a carotid-cavernous sinus fistula within three weeks after a craniocerebral injury. Despite initial exclusion of an arteriovenous fistula using duplex sonography, angiography later demonstrated the carotid-cavernous sinus fistula that was successfully occluded be means of catheter intervention. The patient's symptomatology consisting of pulse synchronous bruit, red, swollen and painful eye, diplopia, chemosis, pulsating exophthalmos, ocular hypertension and progressive visual loss allowed various differential diagnoses. Apart from inflammatory, mechanical, autoimmune, vascular and tumorous disorders, a traumatic cause was highly probable considering the patient's history of craniocerebral injury. A rapid elimination of such a fistula is necessary in order to prevent long-term damage. However it is important to consider the possible complications due to the intervention, in our case the risk of a hyperperfusion syndrome with a consecutive cerebral hemorrhage.

Transarterial embolization of traumatic carotid-superior hypophyseal arterial cavernous fistula. A case report

A 26-year-old man presented with symptoms of progressive bilateral exophthalmos and swelling of the eyelids after a severe head injury. Angiography confirmed a direct carotid-superior hypophyseal arterial (SHA) cavernous fistula with petrosal sinus and intracavernous sinus drainage. Successful transarterial coil embolization of the fistula was performed with resolution of the patient's symptoms. To our knowledge, post-traumatic arteriovenous fistula between SHA and the cavernous sinus has not been previously reported. We hereby demonstrate an effective, minimally invasive method of occluding a rare fistula by transarterial embolization.

Transvenous embolization of dural carotid cavernous fistulas: a series of 44 consecutive patients

BACKGROUND AND PURPOSE

Endovascular TVE for DCCF is used for curative purposes, but serious complications can be caused with inadequate embolization. Our aim was to report clinical characteristics, angiographic findings, and results of endovascular TVE in patients presenting with DCCF.

MATERIALS AND METHODS

We performed a retrospective analysis of 44 consecutive patients with DCCF treated by TVE. Approach routes, angiographic results, clinical outcomes, and complications were assessed.

RESULTS

An approach via the internal jugular vein and inferior petrosal sinus was possible in 90% of patients, with complete occlusion of the fistula in 81.6% of patients. A minor residual shunt remained in 13.6% of patients, while a significant shunt remained in 4.5%. In 4 patients, add-on management with transarterial embolization was useful, and in 2 patients with residual shunt, radiosurgery was used. With long-term follow-up (6-40 months), we encountered recanalization/recurrence in 4 patients (9.1%). Complications were seen in the form of permanent morbidity in 3 patients (7%) and transient morbidity in 6 patients (14%).

CONCLUSIONS

For endovascular treatment of DCCF, a transvenous approach was effective in most of our patients; however, some adverse effects were encountered. If AV shunts remain after transvenous treatment, additional modalities must be considered.

[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.

Transarterial coil embolization of a carotid-cavernous fistula which occurred during stent angioplasty

Intracranial endovascular procedures are less invasive and relatively safe; however, these procedures do carry a risk of complications, such as thromboembolization, arterial injury, and vessel occlusion. We present a case of carotid-cavernous fistula development secondary to injury of the cavernous segment of the internal carotid artery (ICA) during stent angioplasty and its treatment by transarterial coil embolization. Probable causes of this complication and its treatment method are discussed. To the best of our knowledge, this is the first report of such a case.

Rupture of an aneurysm of the persistent trigeminal artery presenting as a carotid-cavernous sinus fistula

A 62-year-old Caucasian female presented with spontaneous right-sided eye pain, chemosis and ophthalmoloplegia. A right carotid-cavernous sinus fistula was discovered and successfully treated with transvenous introduction of Guglielmi detachable coils. In addition to complete fistula occlusion, follow-up angiography 6 weeks post-treatment demonstrated the presence of a patent persistent trigeminal artery previously hidden by the caliber of the carotid-cavernous sinus fistula. The spontaneous nature of the presentation and the proximity of the persistent trigeminal artery to the site of coil embolization suggest spontaneous rupture of a persistent trigeminal artery aneurysm as cause of the fistula. Current literature on this finding is discussed here, demonstrating that an aneurysm of the persistent trigeminal artery leading to carotid-cavernous sinus fistula formation is rare. Furthermore, the present case is the first report of its kind in world ophthalmology literature.

[Orbital approach for treatment of carotid-cavernous sinus fistula]

CASE REPORT

A male patient with a left carotid-cavernous sinus fistula (CCSF) and two previous attempts of embolization via the femoral vein was treated with embolization through the superior ophthalmic vein (SOV).

DISCUSSION

The main modality of treatment for CCSF is intervention radiology. This aims to occlude the fistula via an arterial route, through the cavernous sinus, or via a venous route, through the inferior petrosus sinus. However, the CCSF is also accessible through the SOV.

Trans-arterial embolisation therapy of dural carotid-cavernous fistulae using low concentration n-butyl-cyanoacrylate

BACKGROUND

Trans-venous embolisation has been accepted as the preferred treatment for dural carotid-cavernous fistulae (DCCF). However, such an approach is not always feasible. In this circumstance, trans-arterial embolisation with low concentration n-butyl-cyanoacrylate glue (NBCA) may be a feasible alternative. We report our results and experience of this method for DCCF.

MATERIALS AND METHODS

Five patients with DCCF were treated by trans-arterial embolisation using low concentration NBCA by wedging the microcatheter into the main feeding artery. All five lesions were associated with venous drainage into the superior ophthalmic vein. The inferior petrosal sinus was patent in one patient and thrombosed in four. Additional venous drainage into the Sylvian vein and the superior petrosal sinus was observed in two patients.

FINDINGS

The definitive NBCA injection was performed via the branches of the middle meningeal artery in three patients and accessory meningeal artery as well as ascending pharyngeal artery in two patients. Four patients showed complete obliteration of the DCCF on the post-embolisation angiogram, and follow-up studies showed clinical cure or improvement and successful obliteration of the DCCF. One patient had a residual DCCF after the procedure, but showed complete obliteration and clinical cure at 5-month follow-up. Glue penetrated into the Sylvian vein in one patient during the procedure without sequelae. Two patients had transient worsening of ocular symptoms after the procedure.

CONCLUSIONS

Trans-arterial embolisation with low concentration NBCA using a wedged microcatheter technique is still a safe and effective treatment for DCCF when the transvenous approach is not feasible. However, care must be taken to prevent inadvertent arterial and venous embolisation.

[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 fistula in CNS choriocarcinoma

Carotid artery-cavernous sinus fistulas (CCFs) are infrequently reported in the pediatric population, and are rarely reported in conjunction with CNS neoplasms. The authors present a 7-year-old girl with CNS choriocarcinoma who acutely developed left eye proptosis and conjunctival injection. Computed tomography angiography revealed a CCF, which was endovascularly embolized with detachable coils. There may be a direct cause-and-effect relationship between choriocarcinoma and development of CCFs.

[A case of direct carotid cavernous fistula, whom three-dimensional computed tomographic angiography was helpful for decision making of selective coil embolization]

We reported the case of an 84-year-old female suffering from chemosis and exophthalmos. Carotid arteriograms revealed a direct carotid-cavernous fistula (CCF) but could not clearly show the fistula point because of its high-flow nature. We then performed three-dimensional computed tomographic angiography (3D-CTA) using a multi detector-row CT (MDCT) scanner. Multi-planar reformatted CT images distinctly revealed a right carotid aneurysm at the cavernous portion and a shunting point between the aneurysm and the cavernous sinus. Based on this information, we opted to performa transvenous coil embolization to treat this patient. Successful selective coil embolization was performed at the fistulous point was done with a smaller number of coils than ordinarily required in sinus packing. Performing 3D-CTA by using a MDCT was helpful in decision making for the selective coil embolization to treat direct CCF.

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.

Traumatic carotid cavernous fistula associated with a mandibular fracture

Carotid cavernous sinus fistula is an abnormal vascular interconnection between a branch of the carotid artery and the cavernous sinus. This is an uncommon complication of craniofacial injuries, as it occurs in only 0.17-0.27% of cases, according to the literature. The differential diagnosis should include superior orbital fissure syndrome, orbital apex syndrome, orbital haematoma and cavernous sinus thrombosis. The case is reported of an 18-year-old white woman who was involved in a motor vehicle accident. Clinical examination revealed only mandibular fractures, with the absence of skull-base, mid-face or any other fractures. Two days after the trauma, her condition deteriorated, and extraocular movements were totally absent. Magnetic resonance angiographic scanning was performed, and a carotid cavernous sinus fistula was found. This was treated by embolization resulting in restoration of eye movement and vision.

Transvenous embolization of dural carotid-cavernous fistulae with transfacial catheterization through the superior ophthalmic vein

OBJECTIVE

We report our experience gaining access to the cavernous sinus via transfacial catheterization of the superior ophthalmic vein through the angular or retromandibular vein. We evaluate the viability of this approach as a safe and convenient alternative pathway for transvenous embolization of the cavernous sinus.

METHODS

This is a retrospective study of 98 patients with symptomatic dural carotid-cavernous fistulae from two major regional hospitals in Hong Kong. All 98 patients presented with one or more ocular symptoms. Seventy-four transvenous embolization procedures were performed on 71 patients. Transvenous access to the cavernous sinus was attempted through various pathways, one by one, until the cavernous sinus was successfully catheterized.

RESULTS

The overall technical success rate of transvenous embolization of dural carotid-cavernous fistulae in our study was 64 out of 74 patients (86.5%). Had we not used the technique of transfacial catheterization, the technical success rate would have been 53 out of 74 patients (71.6%). After adoption of the transfacial approach, the technical success rate of transvenous embolization became 64 out of 64 patients (100%). Residual symptoms occurred in eight patients. Two patients developed transient VIth cranial nerve palsy after transvenous embolization for 1 and 2 months, respectively. Otherwise, there were no complications.

CONCLUSION

Transfacial catheterization through the superior ophthalmic vein is a safe and effective approach and provides a convenient alternative pathway for transvenous embolization of dural carotid-cavernous fistulae when cannulation of the inferior petrosal sinus is not successful, thereby increasing the technical success rate.