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

Outcomes After Endovascular Treatment of Direct Carotid Cavernous Fistulas: Systematic Review and Meta-Analysis

BACKGROUND

Direct carotid cavernous fistulas (dCCF) involve pathologic shunting from the internal carotid artery into the cavernous sinus. We systematically reviewed the methods and outcomes of endovascular therapy for dCCF.

METHODS

PubMed, Scopus, and EMBASE were used to identify studies that reported outcomes for patients undergoing embolization of dCCF. Outcomes included rates of occlusion, complications, symptom improvement, and recurrence. Pooled rates for each outcome were obtained with random effects models. The influence of embolization method on outcomes was assessed with meta-regressions.

RESULTS

There were 16 studies comprising 270 patients. The mean age was 39.6 years, there were 36.3% females, and the mean follow-up was 19.7 months. Coils were the most common method of embolization (69.3%), followed by Onyx (31.1%), covered stent (22.2%), N-butyl cyanoacrylate (6.7%), and flow diversion (4.8%). The pooled overall occlusion rate was 92.1% (95% confidence interval [CI], 86.3-95.6; I2 = 29.2%). The pooled complication rate was 10.9% (95% CI, 7.3-16; I2 = 0%). Use of coils were associated with a slightly lower odds of overall complications (odds ratio, 0.98; 95% CI, 0.97-0.99) and cranial nerve palsy (odds ratio, 0.98; 95% CI, 0.97-0.99). The pooled fistula recurrence rate was 8.3% (95% CI, 4.3-15.4; I2 = 30.9%).

CONCLUSIONS

Endovascular therapy for dCCF is associated with high occlusion and low complication rates. Recurrence is not uncommon, highlighting the need for close follow-up.

Clinical Improvement of Patients with Endovascular Treatment in the Traumatic Carotid-Cavernous Fistula

A carotid-cavernous sinus fistula (CCF) is a clinical condition when there is an abnormal communication between the internal carotid artery, external carotid artery (ECA), or any of their branches to the cavernous sinus. Traumatic CCF (TCCF) is the most common type of all CCFs. This study aims to find clinical improvement of traumatic carotid-cavernous fistulas (TCCF) after endovascular treatment. We predict the degree of clinical recovery in an attempt to make the treatment of TCCF safe and effective. This study reported a series of 28 patients with TCCFs undergoing coiling and ballooning in a period of 3 years, i.e., from December 2014 to December 2017. This is a novel case report about CCF in our country, Indonesia, especially in Surabaya. We performed clinical, angiographical, and radiological assessments before and at regular time periods after the procedure until 6 months. All patients had a partial and complete occlusion of the fistula. Angiographic occlusion of fistula, visualization of the ophthalmic artery, and disappearance of bruit predicted a good clinical outcome. All patients made a recovery at different times, depending on the degree of fistulas and treatment. Improvement in clinical symptoms had a direct correlation with the degree of occlusion. Treatment was divided into coiling and ballooning depending on patient's condition and angiographic examination. Trans femoral cerebral angiography is still very important diagnostic tool in the diagnosis and treatment of TCCFs.

Digital intravascular pressure wave recording during endovascular treatment reveals abnormal shunting flow in vertebral venous fistula of the vertebral artery: illustrative case

BACKGROUND

An arteriovenous fistula is an abnormal arteriovenous shunt between an artery and a vein, which often leads to venous congestion in the central nervous system. The blood flow near the fistula is different from normal artery flow. A novel method to detect the abnormal shunting flow or pressure near the fistula is needed.

OBSERVATIONS

A 76-year-old woman presented to the authors’ institute with progressive right upper limb weakness. Right vertebral angiography showed a fistula between the right extracranial vertebral artery (VA) and the right vertebral venous plexus at the C7 level. The patient underwent endovascular treatment for shunt flow reduction. Before the procedure, blood pressures were measured at the proximal VA, distal VA near the fistula, and just at the fistula and drainer using a microcatheter. The blood pressure waveforms were characteristically different in terms of resistance index, half-decay time, and appearance of dicrotic notch. The fistula was embolized with coils and N-butyl cyanoacrylate solution.

LESSONS

During endovascular treatment, the authors were able to digitally record the vascular pressure waveform from the tip of the microcatheter and succeeded in calculating several parameters that characterize the shunting flow. Furthermore, these parameters could help recognize the abnormal blood flow, allowing a safer endovascular surgery.

Transvenous Onyx Embolization of Carotid-Cavernous Fistulas: Mid- and Long-Term Outcomes

Objective  Endovascular treatment of carotid-cavernous fistulas (CCFs) has been consistently shown to give excellent results and is currently the mainstay of treatment of these complex vascular pathologies. Onyx is currently the most widely used agent, but there has been concern over high rates of cranial nerve (CN) deficits seen in patients with CCF treated with Onyx and paucity of data on long-term outcomes. Methods  This is a retrospective analysis of patients who underwent transvenous Onyx embolization between 2011 and 2018. The data collected included demographics, comorbidities, presenting symptoms, CCF morphology, degree of obliteration, procedure-related complications, clinical outcomes, and follow-up. Results  A total of seven patients (five females) were included. The median age was 66 years (range: 15-79 years). Median duration of symptoms before treatment was 4 weeks (range: 1-24 weeks). There were three direct and four indirect CCFs. Barrow classification is as follows: A-3; B-3; C-0; and D-1. Immediate complete occlusion was achieved in all cases. There was also one case of immediate postoperative change in CN function (new partial CN VI deficit) that resolved completely at 1-month follow-up. The mean length of stay was 3 days (±2). The preoperative extraocular movement CN deficits had the following outcomes: three resolved; two improved; and one persisted. Proptosis, chemosis, conjunctival injection, and tinnitus were resolved in all patients. The median follow-up was 34 months (range: 10-91 months). Conclusion  Transvenous Onyx embolization is a safe and effective treatment of CCFs when technical aspects to reduce complications are performed diligently. Our technique demonstrates safety of the Onyx as a stand-alone embolization for the treatment of CCF.

Objective Assessment of Arterial Steal Phenomenon in Direct Carotid Cavernous Fistula Using 2D Parametric Parenchymal Blood Flow Analysis

The aim of the study is to evaluate the hemodynamic changes and the parenchymal perfusion associated with carotid cavernous fistulas before and after embolization using two-dimensional (2D) parenchymal blood flow analysis. A 15-year-old boy presented with 2-month history of progressive right eye proptosis, chemosis, and diplopia after a motor vehicle accident. Intracranial liquid embolization using Onyx-18 through the inferior petrosal approach was done with balloon protection at the opening of the fistula in the internal carotid artery, resulting in complete occlusion of the fistula. Parenchymal blood flow analysis was done before and immediately after embolization. 2D parametric parenchymal blood flow analysis is newly introduced software that can provide data cannot be conveyed by conventional digital subtraction angiography alone. The software allows for objective assessment of the arterial steal and the parenchymal perfusion both pre, and post-embolization. Pre-embolization assessment may influence the therapeutic decision, while post-embolization assessment can evaluate the treatment efficacy.

Traumatic arteriovenous fistula between the extracranial middle meningeal artery and the pterygoid plexus: A case report and literature review

The formation of a traumatic arteriovenous fistula (AVF) between the extracranial middle meningeal artery (MMA) and the pterygoid plexus (PP) is very rare, and understanding of this condition is limited. This paper reports the case of an 8-year-old who suffered minor injuries after a high fall four months prior to admission and showed good recovery after one month. However, the child gradually developed exophthalmos of the left eye and conjunctival redness one month prior to admission. Auscultation revealed an intracranial murmur near the left side of the face, in the temporal region. A digital subtraction angiography (DSA) showed rupture of the left extracranial MMA and an AVF between the MMA and the PP. The blood drained toward the cavernous sinus, resulting in retrograde blood flow into the ophthalmic vein and the cortical vein. The diagnosis was an AVF between the MMA and the PP, and a combination of coils and Onyx liquid embolic agent was employed to perform AVF embolization. Follow-up six months later indicated no recurrence of the AVF, and the patient showed good recovery with a normal-appearing left eye. The AVF in this case drained toward the cavernous sinus, and symptoms of increased intracranial venous system pressure were apparent, similar to those produced by fistulas between the internal carotid artery and the cavernous sinus. This condition is very rare, and the use of coils in combination with Onyx for AVF embolization is novel, warranting the reporting of the current case.

Assessment of clinical improvement in patients undergoing endovascular coiling in traumatic carotid cavernous fistulas

OBJECTIVES

We attempt to find key points in endovascular coiling which can help us predict degree of clinical recovery, in an attempt to make the treatment of CCF safe and effective.

PATIENTS AND METHODS

We analyzed a series of 15 patients with traumatic CCFs undergoing coiling by performing clinical, angiographical and radiological assessment before and at regular time periods after the procedure till 6 months. The findings were analyzed to find critical points predicting clinical outcome in each of the patients.

RESULTS

80% patients had complete occlusion of fistula (n=12) with a 100% ICA patency rate. Angiographic occlusion of fistula, visualization of ophthalmic artery and disappearance of bruit predicted a good clinical outcome. Cranial nerve palsies and fixed neurological deficits do not always reverse suggesting an alternate etiopathology.

CONCLUSION

The degree of occlusion had direct correlation with improvement in clinical symptoms, which was remarkable when the extent of occlusion was more than 90%. To our knowledge this is one of the largest series in published literature on clinical outcomes of patients with traumatic CCFs using detachable coils as the embolizing agent and can serve as standard for comparison for future treatment alternatives.