Dural carotid cavernous fistula: definitive endovascular management and long-term follow-up

PURPOSE

To describe the endovascular treatment and clinical outcome in patients with indirect carotid cavernous fistulas (CCFs) over a 15-year period. To our knowledge, this is the largest series in the medical literature.

DESIGN

Interventional case series.

METHODS

A retrospective evaluation of 135 consecutive patients who underwent examination and treatment for indirect CCF was performed. Patients received independent evaluations by ophthalmologists, neurologists, or neuro-ophthalmologists before, during, and after endovascular treatment. Patients initially received noninvasive imaging followed by cerebral arteriography for definitive diagnosis and stratification by angiographic risk factors. Endovascular treatment was performed in 133 (98%) patients and clinical follow-up was achieved in 135 (100%) patients on an average of 56 +/- 4.3 months (range: 2 months-14 years). Angiographic follow-up was performed in 72 (54%) patients with ongoing symptoms or a history of fistula with high-risk angiographic features. Arteriographic cure with long-term clinical outcome is summarized by modified Rankin scale (mRS) and Barthel index (BI).

RESULTS

At a mean follow-up of 56 months, 121 (90%) patients were clinically cured. At latest clinical follow-up, 131 (97%) patients showed good recovery (mRS, 1-2; BI 90-100), one (1%) had moderate disability (mRS, 3; BI, 50-60), and three (2%) (mRS, 4; BI, 40-50) were severely disabled. Procedure-related permanent morbidity was 2.3%. There was no operative mortality.

CONCLUSIONS

With the observed favorable outcomes and low rate of procedural morbidity in this patient population with long-term angiographic and clinical follow-up, endovascular therapy should be the primary treatment for patients with indirect (dural) fistulas of the cavernous sinus.

The case of low symptoms carotid cavernous fistula

The authors describe the case of a patient with posttraumatic carotid cavernous sinus fistula with a complex of low clinical syndromes. Attention was drawn to oligosymptomatic fistula causing diagnostic difficulties in maxillofacial surgery practice. The study presents diagnostic and treatment methods and their results.

Spontaneous direct carotid-cavernous fistula in Ehlers-Danlos syndrome type IV: two case reports and a review of the literature

Two unrelated adults with Ehlers-Danlos syndrome type IV developed acute unilateral ophthalmoplegia and ipsilateral headache as a consequence of spontaneous (nontraumatic) direct carotid-cavernous fistulas. Because the interventional radiologist suspected the diagnosis of Ehlers-Danlos syndrome type IV, the carotid-cavernous fistulas were closed via the venous rather than the more standard arterial route in an attempt to avoid arterial dissection or rupture. In any patient presenting with a spontaneous direct carotid-cavernous fistula, family history and clinical examination should be targeted toward a diagnosis of Ehlers-Danlos syndrome type IV because of risks attendant to angiography and repair of the fistula. For these patients, ancillary medical care must be approached cautiously to avoid hollow viscus rupture. Molecular tests can be used to confirm the diagnosis and provide family members with accurate genetic counseling and predictive genetic testing.

Surgical transvenous embolization of a carotid-cavernous dural fistula with cortical drainage via a petrosal vein: two technical case reports

OBJECTIVE AND IMPORTANCE

We present two interesting cases involving carotid-cavernous dural fistulae draining only or predominantly into the petrosal vein after previous incomplete, complicated, endovascular treatments. Transvenous embolization with Guglielmi detachable coils, via the petrosal vein, during surgical exposure completely obliterated the fistulae.

CLINICAL PRESENTATION

A 64-year-old man manifesting left ocular symptoms after incomplete embolization of a left carotid-cavernous dural fistula and a 56-year-old woman manifesting left hemiparesis after complicated embolization of a right carotid-cavernous dural fistula were referred to our hospital. A percutaneous transvenous approach was attempted in both cases, but the catheter could not reach the fistula site. A combined open surgical and endovascular approach was then used.

INTERVENTION

The hemispheric branch of the petrosal vein was exposed via a retromastoid craniectomy. The catheter was then directly introduced into the hemispheric branch, followed by navigation into the fistula site. The fistula was completely embolized with Guglielmi detachable coils.

CONCLUSION

The technique of surgical transvenous embolization via a petrosal vein is a valuable alternative for the treatment of carotid-cavernous dural fistulae that drain only or predominantly into the petrosal vein, when the percutaneous transvenous route is not accessible.

[Post-traumatic pulsating exophthalmus coexisting with congenital carotid-cavernous fistula]

Pulsating exophthalmus develops most frequently in the course of penetrating or bitemporal head trauma. Idiopathic form is even more rare. Orbit venous system over-loading with pathological arterial blood infiltration is the cause of pulsating exophthalmus. A patient with congenital carotid-cavernous fistula (right eyeball enlargement and noise), suffering from head trauma after road accident has been presented. Carotid-cavernous fistula was diagnosed and than treated casually by endovascular closure of the infiltration between internal carotid artery and cavernous sinus. After 5-month treatment regression of the noise and exophthalmus was observed.

Internal carotid artery pseudoaneurysm masquerading as a peritonsillar abscess

Blunt carotid arterial injuries are uncommon. Motor vehicle crashes are the most frequent cause, but this type of vascular injury can be secondary to any direct blow to the neck, intraoral trauma, or strangulation. Types of vascular injuries include dissection, pseudoaneurysm, thrombosis, rupture, and arteriovenous fistula formation. Patients with pseudoaneurysm of the internal carotid artery will usually present with neurologic complaints, ranging from the minor to complete stroke. On physical examination, neck hematoma, bruits, pulsatile neck mass, or a palpable thrill may be found. However, in 50% of cases, no external signs of neck trauma are observed. Onset of symptoms may occur within a few hours to several months after the initial injury. Angiography is considered the gold standard for diagnosis, but carotid Doppler ultrasound recently has been shown to be very sensitive in detecting these types of injuries. Treatment of pseudoaneurysm is often surgical, with endovascular stenting.

[Direct carotid-cavernous fistulas: endovascular treatment using a detachable balloon]

INTRODUCTION

Carotid cavernous fistulas are abnormal communications between the cavernous sinus and the internal and/or external carotid artery. They may be spontaneous or acquired. Two basic types are distinguished as a function of the aetiology, clinical features and treatment. The direct type is usually due to trauma while the indirect is of varied aetiology.

CLINICAL CASE

We present a series of seven cases of direct carotid-cavernous fistulas, four post-traumatic and three spontaneous, with initial symptoms of ocular involvement and ophthalmoparesia predominantly. All were treated, in our hospital, by embolization with a detachable balloon in the venous variant of the fistula in six cases and by carotid occlusion in one case. Only one severe complication due to distal embolization occurred.

CONCLUSIONS

It is necessary to consider the diagnosis of carotid-cavernous fistulas in patients complaining of acute alterations of ocular motility, headache and/or other ocular symptoms, especially when there is a clinical history of head injury. There should be minimal delay between diagnosis and treatment since there is a high risk of hemorrhage and irreversible sequelae caused by alteration of the venous drainage when they are long-standing. The treatment of choice for direct fistulas is by detachable balloon, which has been shown to be superior to other techniques.

[An indirect carotid-cavernous fistula complicated by secondary glaucoma. Case report]

The authors present clinical picture, diagnostic procedures and therapy of the dural shunt syndrome which is very often the cause of diagnostic difficulties. They report about unusual complication--secondary angle closure glaucoma and venous stasis retinopathy from thrombosis of ophthalmic vein and about the possibilities of the therapy.

Transvenous embolization of carotid cavernous fistulas via the superior ophthalmic vein

BACKGROUND

Treatment of choice for symptomatic carotid-cavernous and cavernous-dural fistulas is neuroradiologic intervention via the femoral artery. Owing to the location of the fistula and/or to anatomic variations, a direct surgical approach via the superior ophthalmic vein may be necessary for embolization.

METHODS

Three patients presented with exophthalmos, episcleral venous congestion, chemosis, restricted eye movement, and secondary glaucoma. One patient had visual impairment and scotoma due to compression of the optic nerve by the fistula. The tentative diagnosis of an arteriovenous fistula was confirmed in two cases by color Doppler imaging and in all three cases with cerebral arterial angiography (two carotid-cavernous fistulas, one cavernous-dural fistula). After an unsuccessful transarterial attempt, embolization via the superior ophthalmic vein was chosen.

RESULTS

In all three patients the preparation of the superior ophthalmic vein was performed without any complications. In two cases the fistula could be embolized completely with platinum coils. In one patient the placement of the microcatheter was impossible, because of an abnormal vascular pattern. Later on the fistula was successfully embolized by an approach via the femoral vein. All three patients had complete resolution of symptoms. There were no recurrences.

CONCLUSION

Embolization of carotid-cavernous and cavernous-dural fistulas by a surgical approach via the superior ophthalmic vein represents safe and effective treatment when standard transarterial access is impossible. The cooperation of an orbital surgeon and an invasive neuroradiologist can be of benefit for this rare group of patients.

Endovascular treatment of a ruptured dual aperture cavernous aneurysm

The authors describe the diagnosis and endovascular management of a multiaperture, ruptured cavernous internal carotid artery aneurysm causing a carotid cavernous fistula (CCF) using both transarterial and transvenous techniques. Although uncommon, recognition of the imaging characteristics of such a lesion will aide in successful management and improve treatment outcome. To the authors' knowledge, CCF due to a ruptured cavernous aneurysm with multiple shunts has not been previously reported.

[Hemiparesis as a sequela of traumatic pseudoaneurysm of the carotid bifurcation]

HISTORY AND CLINICAL FINDINGS

A 20-year-old patient was referred to our clinic after sudden onset of a left-sided hemiparesis. His past history revealed a severe trauma 4 years ago, including multiple bone fractures, rupture of the spleen, as well as renal failure, and an acute respiratory distress syndrome, from which he showed good recovery. At that time no central-nervous symptoms could be found. However, eighteen months ago, he complained about a transient weakness of his left arm and leg.

INVESTIGATIONS

Examination of the cerebral arteries by duplex-sonography showed an aneurysm on the bifurcation of the right carotid artery with a peripheral flow-reduction. This could be confirmed by CT- and MR-based angiography, which also revealed a reopened embolic occlusion of the M1-segment of the right middle cerebral artery. On CT and diffusion weighted imaging there was evidence of an ischemic infarction pattern.

TREATMENT AND COURSE

Under anticoagulation therapy with heparin the patient showed complete recovery from his symptoms. Duplex-sonography as well as MR-angiography documented a complete reopening of the primarily occluded middle cerebral artery. Finally, surgical reconstruction of the aneurysmatic part of the vessel was done.

CONCLUSION

This case illustrates the potential risk of a traumatic aneurysm as a potential source of ischemic brain infarctions. We emphasize the importance of imaging the cerebral arteries in traumatic patients, even in the absence of initial neurological symptom.

Multimodality monitoring and the diagnosis of traumatic caroticocavernous fistula following head injury

Increases in jugular bulb saturations (SjO2) following head injury are usually due to hyperaemia. Less commonly this may be due to the development of an arteriovenous fistula. We describe how SjO2 monitoring can be used in conjunction with transcranial Doppler ultrasound to make the distinction between these two conditions, which require distinct therapies. Multimodality monitoring in acute injury provides information regarding underlying pathophysiology and permits individualization of therapy.

Indirect carotid cavernous fistula presenting as pulsatile tinnitus

This paper reports a case of spontaneous indirect carotid cavernous fistula that presented with pulsatile tinnitus, left-sided temporal headache and left-sided ptosis. The pulsatile tinnitus, its aetiology and investigation are discussed. The importance of pulsatile tinnitus is highlighted, with a discussion of carotid-cavernous fistulas. This case illustrates that clinically silent cavernous sinus thrombosis can give rise to spontaneous indirect carotid cavernous fistula. Magnetic resonance imaging angiography was used in diagnosis. Treatment ranges from observation, as in our case, to transvenous endovascular techniques.

[Main symptom: "pulse-synchronous tinnitus"]

BACKGROUND

In comparison to cochlear or nerval generated ear noises, pulsatile tinnitus is a rare condition. Due to its own etiology, specific diagnostic steps are necessary.

PATIENTS

We present 6 patients with pulsating tinnitus as the leading symptom. By means of these cases the various etiologies, rational diagnosis and therapy will be discussed.

RESULTS

Pulsatile tinnitus is frequently caused by an increased blood flow in the cranial vessels through various pathologies. Besides those diseases going along with a general increase of blood circulation, regional alterations can be classified as hypervascular/hyperemic, arterial or venous conditioned.

CONCLUSIONS

Physical examination and modern imaging can detect the underlying reasons in a quick and reliable way.

A bruital headache and double vision

A 44-year-old woman presented with a painful abducens nerve palsy in the left eye. Examination revealed a white, quiet eye and an orbital bruit without proptosis. Magnetic resonance imaging demonstrated abnormal ipsilateral dural-based enhancement. Angiography confirmed a posterior draining carotid-cavernous fistula. Symptoms resolved spontaneously in approximately 8 months. The classification and treatment options for carotid-cavernous fistula are discussed.