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Yu J. Endovascular treatment of traumatic anterior communicating artery-cavernous sinus fistula. Neuroradiol J 2024; 37:372-375. [PMID: 37579065 PMCID: PMC11138333 DOI: 10.1177/19714009231196469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Traumatic anterior communicating artery (AcomA)-cavernous sinus (CS) fistula is rare. Flow diverter (FD) deployment associated with coiling may be an alternative but has never been reported. We reported such a case. A 61-year-old man who was involved in a traffic accident presented with progressive exophthalmos for 2 weeks. Digital subtraction angiography showed a fistula between the AcomA and CS. First, the fistula was coiled. Then, the FD was deployed to cover the rupture point of the AcomA. The fistula was obliterated. Postoperatively, the patient recovered well, and his eye symptoms disappeared. Follow-up angiography showed no recurrence of the fistula. Therefore, for traumatic AcomA-CS fistula, FD deployment associated with coiling may be a feasible alternative.
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Affiliation(s)
- Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
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2
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Ouyang G, Zheng KL, Luo K, Qiao M, Zhu Y, Pan DR. Endovascular treatment of direct carotid cavernous fistula resulting from rupture of intracavernous carotid aneurysm: A case report. World J Clin Cases 2024; 12:1940-1946. [PMID: 38660547 PMCID: PMC11036523 DOI: 10.12998/wjcc.v12.i11.1940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/02/2024] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Direct carotid cavernous fistulas (CCFs) are typically the result of a severe traumatic brain injury. High-flow arteriovenous shunts secondary to rupture of an intracavernous aneurysm, resulting in direct CCFs, are rare. The use of a pipeline embolization device in conjunction with coils and Onyx glue for treatment of direct high-flow CCF resulting from ruptured cavernous carotid artery aneurysm in a clinical setting is not well documented. CASE SUMMARY A 58-year-old woman presented to our department with symptoms of blepharoptosis and intracranial bruits for 1 wk. During physical examination, there was right eye exophthalmos and ocular motor palsy. The rest of the neurological examination was clear. Notably, the patient had no history of head injury. The patient was treated with a pipeline embolization device in the ipsilateral internal carotid artery across the fistula. Coils and Onyx were placed through the femoral venous route, followed by placement of the pipeline embolization device with assistance from a balloon-coiling technique. No intraoperative or perioperative complications occurred. Preoperative symptoms of bulbar hyperemia and bruits subsided immediately after the operation. CONCLUSION Pipeline embolization device in conjunction with coiling and Onyx may be a safe and effective approach for direct CCFs.
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Affiliation(s)
- Guang Ouyang
- Department of Neurosurgery, Puren Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, China
| | - Kai-Li Zheng
- Department of Neurosurgery, Puren Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, China
| | - Kuan Luo
- Department of Neurosurgery, Puren Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, China
| | - Mu Qiao
- Department of Neurosurgery, Puren Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, China
| | - Yuan Zhu
- Department of Neurosurgery, The Third Hospital of Wuhan, Wuhan 430081, Hubei Province, China
| | - De-Rui Pan
- Department of Neurosurgery, Puren Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, China
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Al-Smadi AS, Ali R, Kappel AD, Intikhab O, Rajah GB, Luqman A. Patch Technique for Primary Treatment of Type A Carotid Cavernous Fistula: A Case Series and Technical Notes. J Neuroophthalmol 2023; 43:541-546. [PMID: 37166977 DOI: 10.1097/wno.0000000000001867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND The utilization of flow diverters (FDs) in the treatment of high-flow Type A carotid cavernous fistulas (CCFs) has been described before mainly as an adjunct to the traditional endovascular techniques and rarely as a stand-alone treatment. In this study, we retrospectively evaluated our experience with FDs as the solo nonadjunctive treatment of Type A CCF with severe cortical venous reflux (CVR). METHODS A retrospective review was performed of patients with Type A CCFs who were treated using FDs' patch technique (PT). Patients' demographics, clinical data, and preoperative and postoperative ocular examination were recorded. The procedure technique, pipeline embolization device (PED) diameters, and immediate and late procedure outcomes were described. RESULTS Three patients were included in this case series. All patients had history of trauma and presented with decreased visual acuity, cranial nerve II deficit, limited extraocular muscles' movement, and increased intraocular pressure (IOP). Diagnostic angiography was performed, which confirmed high-flow Type A CCF. Endovascular treatment was performed through distal radial access in 2 patients and femoral access in 1 patient by deploying 4 sequentially enlarging PEDs with immediate resolution of the ocular symptoms. Follow-up angiography confirmed complete resolution of CCF in 2 patients. One patient was lost to follow-up; however, angiogram at 4 months demonstrated residual small CCF with significant improvement from postprocedure angiogram. CONCLUSIONS The patch technique using sequentially enlarging FDs is a reasonable alternative solo technique for the treatment of direct CCF symptoms and results in immediate resolution of CVR while preserving the cavernous sinus anatomy.
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Affiliation(s)
- Anas S Al-Smadi
- Department of Neuroradiology (ASA-S, OI), The University of Chicago, Chicago, Illinois; Departments of Radiology (RA) and Neurosurgery (ADK, GBR, AL), School of Medicine, Wayne State University, Detroit, Michigan; and Department of Neurosurgery (GBR), Munson Medical Center, Traverse City, Michigan
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Brunasso L, Casamassima N, Abrignani S, Sturiale CL, Incandela F, Giammalva GR, Iacopino DG, Maugeri R, Craparo G. Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication? Surg Neurol Int 2023; 14:65. [PMID: 36895234 PMCID: PMC9990788 DOI: 10.25259/sni_1113_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/03/2023] [Indexed: 03/11/2023] Open
Abstract
Background Flow diversion (FD) is an established treatment for large or giant wide-necked unruptured intracranial aneurysms. In the past few years, the use of flow diverter devices was extended to several other "off-label" indications, including solitary or adjunctive treatment to coil embolization for direct (Barrow A type) carotid cavernous fistulas (CCFs). The use of liquid embolic agents still represents the first-line treatment for indirect CCFs. Typically, the ipsilateral inferior petrosal sinus or superior ophthalmic vein (SOV) is the preferred transvenous routes to access CCFs. In some cases, vessel tortuosity or different features make the endovascular access challenging, thus requiring different approaches and strategies. The aim of the study is to discuss rational and technical aspect in treating indirect CCFs referring to the most up-to-date literature. An alternative experience-based endovascular strategy with FD is described. Methods We report the case of a 54-year-old woman diagnosed with indirect CCF and treated with flow diverter stent. Results After multiple unsuccessful attempts at transarterial right SOV catheterization, a right indirect CCF fed by a single trunk at the ophthalmic origin from the internal carotid artery (ICA) was treated by ICA stand-alone FD. Blood flow was redirect and successfully reduced through the fistula, with immediately postprocedure improvement of the patient's clinical status (ipsilateral proptosis and chemosis). Ten-months radiological follow-up showed the complete obliteration of the fistula. No adjunctive endovascular treatment was performed. Conclusion FD appears a reasonable alternative stand-alone endovascular strategy also for selected difficult-to-access indirect CCFs, when all conventional routes are judged unfeasible. Further investigations will be necessary to better define and support this potential lesson-learned application.
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Affiliation(s)
- Lara Brunasso
- Neurosurgical Clinic, Azienda Ospedaliera Universitaria Policlinico (AOUP) "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo
| | - Nicola Casamassima
- Department of Neuroradiology, Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) Civico Hospital, Palermo
| | - Sergio Abrignani
- Department of Neuroradiology, Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) Civico Hospital, Palermo
| | - Carmelo Lucio Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Palermo, Italy
| | - Francesca Incandela
- Department of Neuroradiology, Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) Civico Hospital, Palermo
| | - Giuseppe Roberto Giammalva
- Neurosurgical Clinic, Azienda Ospedaliera Universitaria Policlinico (AOUP) "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, Azienda Ospedaliera Universitaria Policlinico (AOUP) "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo
| | - Rosario Maugeri
- Neurosurgical Clinic, Azienda Ospedaliera Universitaria Policlinico (AOUP) "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo
| | - Giuseppe Craparo
- Department of Neuroradiology, Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) Civico Hospital, Palermo
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Fana M, Alsrouji O, Rehman M. Pipeline Embolization Stent for the Treatment of Giant Supraclinoid Aneurysms: A Case Series. Cureus 2022; 14:e23674. [PMID: 35510007 PMCID: PMC9060751 DOI: 10.7759/cureus.23674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 11/14/2022] Open
Abstract
Cerebrovascular aneurysms of the supraclinoid region are a technical challenge and can be particularly difficult to treat when greater than 25 mm in diameter. Such giant aneurysms can be approached with various skull-based and endovascular surgical techniques, and the advent of the Pipeline embolization stent presents a new treatment modality. Previously used for the treatment of small aneurysms, the Pipeline embolization device (PED) is a flow diverter device that has more recently been investigated in its use for the treatment of giant aneurysms with few studies to date published about its procedural outcomes. Here, we highlight the case of three patients (two elderly and one middle-aged) presenting symptomatically with giant supraclinoid aneurysms of the cavernous internal carotid artery (ICA) and posterior communicating artery treated with the Pipeline stent and monitored on follow-up visits. We further review the most current case reports and the two clinical trials to date investigating the utility of the Pipeline stent in the treatment of large and giant cerebral aneurysms, highlighting the emerging evidence of its efficacy and long-term patient outcomes. We report successful resolution of symptoms and radiographic evidence of aneurysm size reduction on all patient follow-ups and suggest the Pipeline embolization device as a novel technique that can be utilized for the treatment of giant cerebrovascular aneurysms with emerging evidence of immediate and long-term success.
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Stamatopoulos T, Anagnostou E, Plakas S, Papachristou K, Lagos P, Samelis A, Derakhshani S, Mitsos A. Treatment of carotid cavernous sinus fistulas with flow diverters. A case report and systematic review. Interv Neuroradiol 2022; 28:70-83. [PMID: 33966468 PMCID: PMC8905080 DOI: 10.1177/15910199211014701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Carotid cavernous fistulas (CCFs) are rare, usually follow head trauma or aneurysmal rupture. Recent treatment options include endovascular techniques such as flow diversion devices (FDDs). OBJECTIVE To present our case treated with FDD application with transarterial cavernous-sinus coiling and present a systematic review on the use and effectiveness of FDDs in CCF treatment. MATERIALS AND METHODS We present our case of CCF treatment with FDD. A search was also conducted in PubMed, EMBASE and Cochrane until November 2020. Reference lists were also cross-checked. RESULTS Including our case, thirty-eight patients were identified with a CCF that was treated with FDDs in sixteen studies. Twenty-two patients were females, nine were males and the rest unidentified. The mean age was 52,6 years (range 17-86, SD± 19.28). Thirty-six patients suffered from direct and two from indirect CCFs. Single FDD was used in four cases, single FDD with embolic materials in eleven cases, multiple overlapping FDDs were used in six cases and multiple overlapping FDDs with embolic materials were used in seventeen cases. Thirty-five patients (92,1%) had clinical improvement, immediate angiographic occlusion was seen in 44,7% of the cases, while long-term occlusion rate was 100% but with variable follow-up periods. One patient (2,6%) presented with a neurological deficit related to FDD deployment. CONCLUSION Targeted treatment of CCFs with single or overlapping FDDs with or without adjunct embolic agents offers a high success rate, both clinically and long-term angiographically compared to other endovascular methods alone. However, further research with multi-center prospective trials is warranted.
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Affiliation(s)
- Theodosios Stamatopoulos
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece,Center of Orthopaedics and Regenerative Medicine (C.O.R.E.), Center for Interdisciplinary Research and Innovation (C.I.R.I.), Aristotle University Thessaloniki, Thessaloniki, Greece,Theodosios Stamatopoulos, Department of Neurosurgery, 401 General Military Hospital of Athens, Panagioti Kanellopoulou and Mesogeion Ave, Athens 11525, Greece.
| | - Evangelos Anagnostou
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
| | - Sotirios Plakas
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
| | | | - Panagiotis Lagos
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
| | - Apostolos Samelis
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
| | - Shahram Derakhshani
- Department of Interventional and Therapeutic Neuroradiology, Queen's University Hospital, Essex Center for Neurological Sciences, London, UK
| | - Aristotelis Mitsos
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
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Jareczek FJ, Padmanaban V, Church EW, Simon SD, Cockroft KM, Wilkinson DA. Balloon-Assisted Roadmap Technique to Enable Flow Diversion of a High-Flow Direct Carotid-Cavernous Fistula. J Stroke Cerebrovasc Dis 2021; 31:106180. [PMID: 34823090 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/06/2021] [Accepted: 10/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The use of flow diverters as a first-line treatment for direct carotid cavernous fistula (CCF) is a relatively new approach in the neurointerventional field which allows obliteration of the fistula with less mass effect from coils in the cavernous sinus. Safe and successful deployment of a flow diverter requires adequate imaging of the parent vessel, which may be challenging in the setting of high-flow CCF without antegrade flow. OBJECTIVE To facilitate adequate parent vessel imaging in the setting of high-flow CCF to enable the safe development of a flow diverter device. METHODS Here we present the case of a patient with delayed presentation of post-traumatic direct CCF after a motor vehicle accident, with no antegrade flow past the fistulous connection. We used temporary balloon occlusion of the fistulous connection to enable road-map imaging of the parent vessel and flow-diverter placement. "Drag and drop" device opening in the middle cerebral artery facilitated better deployment of the flow-diverter against retrograde cavernous flow through the fistula. RESULTS Temporary balloon occlusion of the fistulous connection was used to acquire a roadmap to facilitate safe deployment of a flow diverter and subsequent treatment of the CCF with transvenous coil embolization, with complete resolution of symptoms. CONCLUSION Balloon-assisted roadmap use is a novel means of visualizing the parent vessel in direct CCF to facilitate safe flow diverter deployment.
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Affiliation(s)
- Francis J Jareczek
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - Varun Padmanaban
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - Ephraim W Church
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - Scott D Simon
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - Kevin M Cockroft
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - D Andrew Wilkinson
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA.
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Suzuki R, Takigawa T, Matsumoto Y, Fujii Y, Nariai Y, Sugiura Y, Kawamura Y, Takano I, Tanaka Y, Nagaishi M, Hyodo A, Suzuki K. Target Coil Embolization Using the Combined Transarterial and Transvenous Balloon-assisted Technique for Traumatic Direct Carotid Cavernous Fistula. NMC Case Rep J 2021; 8:13-19. [PMID: 34012743 PMCID: PMC8116922 DOI: 10.2176/nmccrj.cr.2020-0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/09/2020] [Indexed: 01/07/2023] Open
Abstract
Herein, we describe a case of traumatic direct carotid cavernous fistula (DCCF) treated with target coil embolization using the combined transarterial and transvenous balloon-assisted technique. The patient was a 59-year-old woman who had been involved in a vehicular accident. She was admitted to the hospital due to chemosis and exophthalmos. Cerebral angiography revealed a shunt from the internal carotid artery (ICA) to the cavernous sinus (CS), which indicated DCCF. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique was performed. Angiography was performed 1 week after surgery to confirm the disappearance of DCCF. No recurrence was observed during the 1-year follow-up after treatment. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique is safe and effective for the treatment of traumatic DCCF.
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Affiliation(s)
- Ryotaro Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yoshiyuki Matsumoto
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yoshiko Fujii
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yasuhiko Nariai
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yoshiki Sugiura
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yosuke Kawamura
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Issei Takano
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yoshihiro Tanaka
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Masaya Nagaishi
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
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Texakalidis P, Tzoumas A, Xenos D, Rivet DJ, Reavey-Cantwell J. Carotid cavernous fistula (CCF) treatment approaches: A systematic literature review and meta-analysis of transarterial and transvenous embolization for direct and indirect CCFs. Clin Neurol Neurosurg 2021; 204:106601. [PMID: 33774507 DOI: 10.1016/j.clineuro.2021.106601] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/04/2021] [Accepted: 03/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Carotid Cavernous Fistulas (CCFs) are the result of an abnormal communication between the carotid artery and its branches and the venous system of the cavernous sinus. The mainstay of therapy for CCFs consists of transarterial or transvenous embolization, while other treatment options such as open surgery or radiosurgery are still utilized as second-line or adjuvant therapeutic options. OBJECTIVE Our aim was to systematically review and summarize available data regarding short- and long-term outcomes of all available treatment modalities for CCFs. METHODS This systematic review was conducted according to the PRISMA guidelines. A random effects model meta-analysis was conducted. RESULTS Fifty-seven studies comprising 1575 patients were included in this systematic review. Transarterial embolization for direct and indirect CCFs offered a complete obliteration rate of 93.93% (N = 589/627) and 81.51% (N = 119/146), respectively. Transvenous embolization for direct and indirect lesions achieved obliteration in 91.67% (N = 33/36) and 86.03% (N = 425/494) of patients, respectively. Comparison between transarterial and transvenous embolization did not reveal statistically significant differences in terms of fistula obliteration for direct (OR: 1.42; 95% CI: 0.23-8.90; I2 0.0%) and indirect CCFs (OR: 0.62; 95% CI: 0.31-1.23; I2 0.0%). CONCLUSIONS Endovascular embolization techniques are the preferred treatment modality for the management of CCFs. No differences were identified between transarterial and transvenous embolization by synthesizing studies with available data. Future prospective cohorts are warranted to compare the different materials and techniques implemented especially within the rapidly expanding realm of endovascular approaches.
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Affiliation(s)
| | - Andreas Tzoumas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Xenos
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dennis J Rivet
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
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Park H, Nakagawa I, Kotsugi M, Myochin K, Kichikawa K, Nakase H. Traumatic carotid-cavernous fistula treated by trans-arterial stent-assisted coil embolization: Technical note. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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11
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Ghorbani M, Lafta G, Rahbarian F, Mortazavi A. Treatment of post-traumatic direct carotid-cavernous fistulas using flow diverting stents: Is it alone satisfactory? J Clin Neurosci 2021; 86:230-234. [PMID: 33775333 DOI: 10.1016/j.jocn.2021.01.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/08/2021] [Accepted: 01/28/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Direct carotid cavernous fistula (CCF) occurs between the internal carotid artery (ICA) and the cavernous sinus. Carotid cavernous fistulas (CCFs) frequently present with chemosis, pulsatile proptosis, ocular bruit, vision loss, and occasionally intracerebral hemorrhage or seizure. In this article, we share our experience in endovascular treatment of six patients having this pathology with intracranial flow diverting stents with review of literatures. CASE DESCRIPTION All six patients had posttraumatic direct CCF, most of their signs and symptoms were visual disturbance, chemosis, orbital bruit, headache, paralysis of extraocular muscles. They were treated with flow diversion stents with or without coils or liquid embolizing material; transvenous and transarterial routes were used. Most of them underwent multiple sessions, and their conditions were improved dramatically. CONCLUSION The best and most effective method is to start the procedure by coiling to convert the high-flow fistula to an aneurysmal pouch with the smallest possible size in the cavernous sinus, and then close the defect site with one or two flow diversion devices (FDDs).
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Affiliation(s)
- Mohammad Ghorbani
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ghazwan Lafta
- Department of Surgery, Faculty of Medicine, University of Al-Ameed, Karbala, Iraq
| | - Farhad Rahbarian
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Abolghasem Mortazavi
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
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Sumdani H, Aguilar-Salinas P, Avila MJ, El-Ghanem M, Dumont TM. Carotid Cavernous Fistula Treatment via Flow Diversion: A Systematic Review of the Literature. World Neurosurg 2021; 149:e369-e377. [PMID: 33578023 DOI: 10.1016/j.wneu.2021.02.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Carotid cavernous fistulas (CCFs) are pathologic connections between the carotid arteries and the cavernous sinus and have been classically treated with endovascular coil embolization, although flow diverters have been used for treatment successfully multiple times. The aim of this study is to systematically review the literature for efficacy of flow diverters in treating CCFs. METHODS A systematic review was conducted using the PRISMA guidelines. PubMed, PubMed Central, Cochrane Library, and Embase databases were searched. Combinations and variations of "carotid cavernous fistula," "flow diversion," "pipeline embolization device," "Surpass," "Silk," "p64," "FRED," and "flow redirection endoluminal device" in both AND and OR configurations were used to gather relevant articles. Citations of included articles from the systematic review were also screened for possible inclusion as a part of manual review. Included studies were full-text publications written in English that had patients with diagnosed CCFs and treatment with flow diversion. RESULTS Eighteen full-text publications were relevant to this systematic review. A total of 41 patients underwent flow-diverting therapy alone or in conjunction with coil embolization, liquid embolization, and/or stenting for treatment of a diagnosed CCF. Twenty-nine patients (70.7%) needed 1 procedure alone, 11 patients (26.8%) required a second procedure, and 1 patient (2.4%) required a third procedure. Six patients (14.6%) had lasting symptoms despite intervention; however, all 41 patients had clinical improvement compared with initial presentation. Flow diversion was a useful solitary treatment or adjunctive treatment in all patients. CONCLUSIONS Flow diversion is a useful adjunct in combination with coil embolization for the treatment of CCFs but long-term outcomes remain to be seen.
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Affiliation(s)
- Hasan Sumdani
- Department of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | | | - Mauricio J Avila
- Department of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | - Mohammad El-Ghanem
- Department of Neurosurgery, University of Arizona, Tucson, Arizona, USA; Department of Neurology, University of Arizona, Tucson, Arizona, USA
| | - Travis M Dumont
- Department of Neurosurgery, University of Arizona, Tucson, Arizona, USA.
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Cossu G, Al-Taha K, Hajdu SD, Daniel RT, Messerer M. Carotid-Cavernous Fistula After Transsphenoidal Surgery: A Rare but Challenging Complication. World Neurosurg 2019; 134:221-227. [PMID: 31712112 DOI: 10.1016/j.wneu.2019.10.194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carotid-cavernous fistula (CCF) is a rare complication after transsphenoidal surgery. METHODS The aim of this article is to report a case of CCF after the endoscopic resection of a growth hormone secreting pituitary microadenoma, and to discuss and review all the cases of CCF secondary to transsphenoidal procedures described in literature. RESULTS A patient aged 74 years was operated for a growth hormone pituitary microadenoma through an endoscopic transsphenoidal surgery. During the procedure, a copious bleeding from the left cavernous sinus was managed with hemostatic material. A direct CCF was diagnosed and managed with transvenous and transarterial coiling. A complete exclusion of the fistula was possible, and the patency of the internal carotid artery was maintained. A total of 9 other cases have been reported. A transsphenoidal approach was performed for sellar tumors in 6 cases, and for chronic sinusitis in 2 cases. In 7 cases, intraoperative hemorrhage was reported, which could be controlled in 5 cases. The postoperative diagnosis of CCF was immediate in 5 cases. Patients presented with persistent bleeding after nasal unpacking or later with chemosis and proptosis. Cerebral angiography was the gold standard for the diagnosis. Eight cases were successfully treated through endovascular techniques with no recurrence observed at follow-up (mean of 15 months). No major neurologic complications were observed. CONCLUSIONS CCF should be suspected with every abnormal bleeding after transsphenoidal surgeries, even when the symptoms are mild. Diagnostic arteriography and endovascular treatment represent the mainstay of the management, and an early diagnosis strongly improves the prognosis.
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Affiliation(s)
- Giulia Cossu
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland.
| | - Khalid Al-Taha
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Steven D Hajdu
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
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14
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Baranoski JF, Ducruet AF, Przbylowski CJ, Almefty RO, Ding D, Catapano JS, Brigeman S, Fredrickson VL, Cavalcanti DD, Albuquerque FC. Flow diverters as a scaffold for treating direct carotid cavernous fistulas. J Neurointerv Surg 2019; 11:1129-1134. [DOI: 10.1136/neurintsurg-2019-014731] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/21/2019] [Accepted: 05/30/2019] [Indexed: 11/04/2022]
Abstract
BackgroundDirect carotid–cavernous sinus fistulas (dCCFs) are high flow arteriovenous shunts between the internal carotid artery and the cavernous sinus. Recently, we have used the pipeline embolization device (PED) to treat dCCFs.MethodsWe describe our experience treating patients with dCCFs in whom the PED was placed as the primary treatment modality.ResultsFive patients with dCCFs were treated with PEDs deployed in the ipsilateral internal carotid artery spanning the fistula. All patients also underwent either adjunctive transvenous or transarterial embolization. The PED served both as the primary treatment modality and as a scaffold that facilitated safe and efficacious transvenous embolysate administration by altering the flow dynamics through the fistula and providing a physical barrier that protected the internal carotid artery. No intraoperative or perioperative complications occurred. One of the five patients exhibited complete angiographic resolution of the fistula immediately after the procedure. The remaining four patients experienced complete obliteration of the fistula without additional treatment, which suggests that the PED induced alteration promoted thrombosis of the fistula. Therefore, 100% of patients in this series exhibited complete and durable obliteration of the fistula and complete resolution of symptoms following treatment.ConclusionsWe believe that use of the PED to treat dCCFs may be a safe and efficacious strategy that facilitates parent vessel protection during transvenous embolization. Furthermore, the flow alterations induced by the PED may promote thrombosis of incompletely occluded fistulas. This is the largest reported series of non-iatrogenic dCCFs treated with use of the PED as the primary initial treatment strategy.
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15
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Atallah E, Saad H, Mouchtouris N, Bekelis K, Walker J, Chalouhi N, Tjoumakaris S, Smith M, Rosenwasser RH, Zarzour H, Herial N, Feghali J, Gooch MR, Missios S, Sweid A, Jabbour P. Pipeline for Distal Cerebral Circulation Aneurysms. Neurosurgery 2019; 85:E477-E484. [DOI: 10.1093/neuros/nyz038] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 01/27/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Pipeline embolization device (PED; Medtronic, Dublin, Ireland) utilization is not limited to the treatment of giant wide-necked aneurysms. It has been expanded to handle small blisters, fusiforms, and dissecting intracranial aneurysms.
OBJECTIVE
To report the use of the PED in various off-label distal cerebral circulation (DCC) arteries with a follow-up to assess clinical outcomes.
METHODS
Between 2011 and 2016, of 437 consecutive patients, 23 patients with aneurysms located in DCCs were treated with PED. Data on patient presentation, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were gathered. To control confounding, we used multivariable logistic regression and propensity score conditioning.
RESULTS
A total of 437 patients (mean age 52.12 years; 62 women [14.2%]) underwent treatment with PED in our institution. Twenty-three of 437 (5.2%) received a pipeline in a distal artery: 11/23 middle cerebral artery, 6/23 posterior cerebral artery, 3/23 anterior cerebral artery (A1/A2, pericallosal artery), and 3/23 posterior inferior cerebellar artery. Twenty percent of the aneurysms were treated in the past, 10% had previously ruptured, and 5.9% ruptured at presentation to our hospital. The mean aneurysm size was 9.0 ± 6 mm. The mean follow-up was 12 mo (SD = 12.5). In multivariable logistic regression, no associations were found between PED deployment in DCCs and aneurysm occlusion or thromboembolic complications. PED use in DCC was associated with a good clinical outcome. Twenty-two people of 23 (95%) had a good clinical outcome in the latest follow-up.
CONCLUSION
Treatment of DCC aneurysms with PED is technically challenging mainly because of the small caliber and tortuosity of the parent arteries. The results of this study further support the safety of flow diverters in the treatment of various distal aneurysms.
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Affiliation(s)
- Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hassan Saad
- Department of Neurological Surgery, Arkansas Neurosciences Institute, Little Rock, Arkansas
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Kimon Bekelis
- Department of Neurological Surgery, Good Samaritan Hospital Medical Center, West Islip, New York
| | - Jackson Walker
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Michelle Smith
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - James Feghali
- Department of Neurosurgery, American University of Beirut, Beirut, Lebanon
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Symeon Missios
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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16
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Hüseyinoglu Z, Oppong MD, Griffin AS, Hauck E. Treatment of direct carotid-cavernous fistulas with flow diversion - does it work? Interv Neuroradiol 2018; 25:135-138. [PMID: 30380952 DOI: 10.1177/1591019918808468] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Direct carotid-cavernous fistulas (CCFs) are high flow lesions that can be challenging to treat. A number of recent reports suggest that flow diversion may be a viable treatment option. We present a case of a post-traumatic CCF successfully treated with flow diversion and provide a review of the literature. Our results suggest that flow diversion is a potentially effective treatment option for CCFs and is most successful when used as an adjunctive therapy.
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Affiliation(s)
| | - Marvin D Oppong
- Duke University Medical Center, Department of Neurosurgery, Durham, USA
| | - Andrew S Griffin
- Duke University Medical Center, Department of Neurosurgery, Durham, USA
| | - Erik Hauck
- Duke University Medical Center, Department of Neurosurgery, Durham, USA
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17
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Al-Mufti F, Cohen ER, Amuluru K, Patel V, El-Ghanem M, Nuoman R, Majmundar N, Dangayach NS, Meyers PM. Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 8:38-54. [PMID: 32231694 DOI: 10.1159/000489016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/06/2018] [Indexed: 12/21/2022]
Abstract
Background Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. Summary We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period. Key Message Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.,Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Eric R Cohen
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh-Hamot, Erie, Pennsylvania, USA
| | - Vikas Patel
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Mohammad El-Ghanem
- Department of Neurology and Medical Imaging, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Rolla Nuoman
- Department of Neurology, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Neil Majmundar
- Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Neha S Dangayach
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Philip M Meyers
- Departments of Radiology and Neurosurgery and Columbia University Medical Center, New York, New York, New York, USA
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18
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Al-Mufti F, Amuluru K, Cohen ER, Patel V, El-Ghanem M, Wajswol E, Dodson V, Al-Marsoummi S, Majmundar N, Dangayach NS, Nuoman R, Gandhi CD. Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms. Oper Neurosurg (Hagerstown) 2018; 15:624-633. [DOI: 10.1093/ons/opy020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 03/15/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract
Flow diverting devices (FDDs) have revolutionized the treatment of morphologically complex intracranial aneurysms such as wide-necked, giant, or fusiform aneurysms. Although FDDs are extremely effective, they carry a small yet significant risk of intraprocedural complications. As the implementation of these devices increases, the ability to predict and rapidly treat complications, especially those that are iatrogenic or intraprocedural in nature, is becoming increasingly more necessary.
Our objective in this paper is to provide a descriptive summary of the various types of intraprocedural complications that may occur during FDDs deployment and how they may best be treated. A systematic and qualitative review of the literature was conducted using electronic databases MEDLINE and Google Scholar. Searches consisted of Boolean operators “AND” and “OR” for the following terms in different combinations: “aneurysm,” “endovascular,” “flow diverter,” “intracranial,” and “pipeline.”
A total of 94 papers were included in our analysis; approximately 87 of these papers dealt with periprocedural endovascular (mainly related to FDDs) complications and their treatment; 7 studies concerned background material. The main categories of periprocedural complications encountered during deployment of FDDs are failure of occlusion, parent vessel injury and/or rupture, spontaneous intraparenchymal hemorrhage, migration or malposition of the FDDs, thromboembolic or ischemic events, and side branch occlusion
Periprocedural complications occur mainly due to thromboembolic events or mechanical issues related to device deployment and placement. With increasing use and expanding versatility of FDDs, the understanding of these complications is vital in order to effectively manage such situations in a timely manner.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Neuro-surgery, and Radiology, Robert Wood Johnson Medical School, Rutgers Uni-versity, New Brunswick, New Jersey
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania
| | - Eric R Cohen
- Department of Radiology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Vikas Patel
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
- Department of Neurology, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Mohammad El-Ghanem
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Ethan Wajswol
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Vincent Dodson
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Sarmad Al-Marsoummi
- Department of Neuroscience, University of North Dakota, Grand Forks, North Dakota
| | - Neil Majmundar
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Neha S Dangayach
- Department of Neurology and Neurosurgery, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Rolla Nuoman
- Department of Neurology, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Chirag D Gandhi
- Department of Neurosurgery, New York Medical College, Westchester Medical Center, New York, New York
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19
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Abstract
RATIONALE Cavernous sinus-carotid fistula (CCF) is a rare complication of craniofacial injuries in patients receiving oral and maxillofacial surgical care. PATIENT CONCERNS A retrospective review of 15 patients with CCF records was conducted. In addition, we present a rare case of a 32-year-old Chinese woman with CCF receiving oral and maxillofacial surgical care. DIAGNOSES Digital subtraction angiography (DSA) confirmed a diagnosis of CCF. INTERVENTIONS Endovascular surgery was performed via the femoral artery under general anesthesia without any complications. OUTCOMES The postoperative course was uneventful, and the subjective and objective ophthalmic symptoms had resolved. LESSONS The symptoms of CCF may be delayed for several days or weeks. Thus, maxillofacial surgeons should be aware of this and avoid the untimely repair of facial fractures with potentially disastrous consequences. Interventional neuroradiologic approaches that involve the use of a detachable balloon have made it possible to care for patients with CCF without any complications.
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Affiliation(s)
- Dong Wang
- Department of Oral and Maxillofacial Surgery, Dongguan People's Hospital, Dongguan
| | - Xiao-Mei Sun
- Department of Pediatrics, West China Second Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Jin Wu
- Department of Pediatrics, West China Second Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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20
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Ogilvy CS, Motiei-Langroudi R, Ghorbani M, Griessenauer CJ, Alturki AY, Thomas AJ. Flow Diverters as Useful Adjunct to Traditional Endovascular Techniques in Treatment of Direct Carotid-Cavernous Fistulas. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.113] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Bender MT, Lin LM, Coon AL, Colby GP. Staged curative treatment of a complex direct carotid-cavernous fistula with a large arterial defect and an 'oversized' internal carotid artery. BMJ Case Rep 2017; 2017:bcr-2017-219662. [PMID: 28619972 DOI: 10.1136/bcr-2017-219662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This is a case of a high-flow, post-traumatic direct carotid-cavernous fistula with a widened arterial defect and a large-diameter internal carotid artery (ICA). The unique aspect of this case is the oversized ICA, >8mm in diameter, which is both a pathological and a therapeutic challenge, given the lack of available neuroendovascular devices for full vessel reconstruction. We present a planned two-stage embolisation paradigm for definitive treatment. Transarterial coil embolisation is performed as the first stage to disconnect the fistula and normalise flow in the ICA. A 3-month recovery period is then allowed for reduction in carotid diameter. Repair of the large vessel defect and pseudoaneurysm is performed as a second stage in a delayed fashion with a flow-diverting device. Follow-up angiography at 6 months demonstrates obliteration of the fistula and curative ICA reconstruction to a diameter <5mm.
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Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Li-Mei Lin
- Department of Neurosurgery, University of California Irvine School of Medicine, Irvine, California, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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22
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Patel PD, Chalouhi N, Atallah E, Tjoumakaris S, Hasan D, Zarzour H, Rosenwasser R, Jabbour P. Off-label uses of the Pipeline embolization device: a review of the literature. Neurosurg Focus 2017; 42:E4. [DOI: 10.3171/2017.3.focus1742] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.
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Affiliation(s)
- Purvee D. Patel
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
- 2Department of Neurological Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; and
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Elias Atallah
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 3Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hekmat Zarzour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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23
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Castaño C, Remollo S, García-Sort R, Domínguez C, Terceño M. Treatment of Barrow type 'B' carotid cavernous fistulas with flow diverter stent (Pipeline). Neuroradiol J 2017; 30:607-614. [PMID: 28374616 DOI: 10.1177/1971400917695319] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Carotid cavernous fistulas (CCFs) Barrow type 'B' are dural shunts between the meningeal branches of the internal carotid artery and the cavernous sinus. The symptoms include vision deterioration, ophthalmoplegia with diplopia, exophthalmos, conjunctival injection, chemosis, ocular bruit, seizures, or neurological deficit. Endovascular treatment remains the gold standard for treatment through the transvenous or transarterial routes. The transvenous approaches have been proved to be the first option. Endovascular access through the superior ophthalmic vein (SOV) or inferior petrosal sinus have been widely used. The problem arises when there is no vascular access. For these cases, different approaches have been described, such as: direct access to the SOV; combining direct access to the SOV along with blind probing of the proximal occluded SOV; and a direct puncture of the cavernous sinus. But these techniques are very aggressive and can cause serious complications. As a result of the above, we describe a new alternative technique, which is effective and less invasive for the treatment of these special cases. Case reports We report two cases of Barrow type 'B' CCFs that did not have vascular access (neither arterial nor venous) to embolise fistulas with coils or glue, and which were successfully resolved with a flow diverter (Pipeline) stent in the internal carotid artery. To our knowledge, this treatment has not previously been described for this pathology. Conclusions The placement of a flow diverter stent in the internal carotid artery is an effective alternative technique in those cases of Barrow type 'B' CCFs that have no vascular access (neither venous nor arterial).
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Affiliation(s)
- Carlos Castaño
- 1 Interventional Neuroradiology Unit, Hospital Universitario Germans Trias i Pujol, Spain
| | - Sebastián Remollo
- 1 Interventional Neuroradiology Unit, Hospital Universitario Germans Trias i Pujol, Spain
| | - Rosa García-Sort
- 1 Interventional Neuroradiology Unit, Hospital Universitario Germans Trias i Pujol, Spain
| | - Carlos Domínguez
- 2 Neurosurgery Department, Hospital Universitario Germans Trias i Pujol, Spain
| | - Mikel Terceño
- 1 Interventional Neuroradiology Unit, Hospital Universitario Germans Trias i Pujol, Spain
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24
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Amuluru K, Al-Mufti F, Gandhi CD, Prestigiacomo CJ, Singh IP. Direct carotid-cavernous fistula: A complication of, and treatment with, flow diversion. Interv Neuroradiol 2016; 22:569-76. [PMID: 27306524 DOI: 10.1177/1591019916653255] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/06/2016] [Indexed: 11/17/2022] Open
Abstract
Direct carotid-cavernous fistulas (CCFs) are rare complications of flow diversion and have typically been documented in a subacute time frame after treatment. We present the first reported case of an intraprocedural direct CCF that developed immediately after flow diversion for treatment of a symptomatic paraclinoid right internal carotid artery aneurysm with a neck involving the cavernous segment. Endovascular treatment of such direct fistulas typically involves either transarterial obliteration of the fistulous site or transvenous embolization of the cavernous sinus. Our case was successfully treated with further immediate flow diversion without additional transvenous intervention. There are few reports on the use of flow diversion for treatment of such direct CCFs, and in all but one of these cases, flow diversion was combined with concomitant transvenous embolization. Thus, the presented case is not only the first reported case of an immediate CCF after flow diversion, but it is also only the second reported case of a direct fistula to be successfully treated using solely flow diversion, without additional transvenous intervention. We review the literature of direct CCFs after flow diversion, the pathophysiology of development of CCFs after flow diversion, the literature on treatment of CCFs with flow diversion as well as all other current treatment options.
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Affiliation(s)
- Krishna Amuluru
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, USA
| | - Chirag D Gandhi
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, USA Department of Neurology, Rutgers University School of Medicine, USA Department of Radiology, Rutgers University School of Medicine, USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, USA Department of Neurology, Rutgers University School of Medicine, USA Department of Radiology, Rutgers University School of Medicine, USA
| | - I Paul Singh
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, USA Department of Neurology, Rutgers University School of Medicine, USA
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25
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Wang W, Li MH, Li YD, Gu BX, Lu HT. Reconstruction of the Internal Carotid Artery After Treatment of Complex Traumatic Direct Carotid-Cavernous Fistulas With the Willis Covered Stent. Neurosurgery 2016; 79:794-805. [DOI: 10.1227/neu.0000000000001266] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Endovascular treatment of complex traumatic direct carotid-cavernous fistulas (TDCCFs) is a challenge.
OBJECTIVE:
To evaluate the long-term efficacy of the Willis covered stent in endovascular treatment of complex TDCCFs, focusing on reconstruction and preservation of the internal carotid artery.
METHODS:
During the past 8 years, 25 patients with 27 TDCCFs who previously had unsuccessful treatment of fistulas with detachable balloons received endovascular treatment with Willis covered stents. The efficacy, complications, in-stent stenosis, angiographic, and clinical follow-up results were evaluated retrospectively between 6 and 88 months (mean, 43.8 months) after the stent placement.
RESULTS:
The technical success rate of stenting placement was 100%. Forty-four Willis covered stents were implanted into the target artery of 27 TDCCFs. Complete exclusion was achieved in 16 patients with 17 TDCCFs immediately after the stent placement, with transient endoleaks in 10 TDCCFs. Redilation was performed in 6 TDCCFs, and additional stents were implanted in the other 4 TDCCFs for endoleak exclusion. The initial angiographic results showed complete exclusion of fistulas with preservation of the internal carotid artery in 24 patients with 26 TDCCFs. One patient in whom complete occlusion initially was achieved subsequently experienced a delayed endoleak, which required placement of an additional stent. The angiographic follow-up results (mean, 30.3 months) demonstrated complete exclusion in all 27 TDCCFs, with patency of internal carotid artery in 23 patients. The clinical follow-up demonstrated a full recovery in 23 patients and improvement in 2 patients.
CONCLUSION:
The use of Willis covered stents was confirmed to be effective, safe, and a curative approach for endovascular treatment of complex TDCCFs and internal carotid artery reconstruction.
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Affiliation(s)
- Wu Wang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ming-Hua Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yong-Dong Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Bin-Xian Gu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hai-Tao Lu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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26
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Wendl CM, Henkes H, Martinez Moreno R, Ganslandt O, Bäzner H, Aguilar Pérez M. Direct carotid cavernous sinus fistulae: vessel reconstruction using flow-diverting implants. Clin Neuroradiol 2016; 27:493-501. [PMID: 27129454 PMCID: PMC5719129 DOI: 10.1007/s00062-016-0511-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 03/02/2016] [Indexed: 11/24/2022]
Abstract
Purpose Retrospective evaluation of our experience with the use of flow diverters (FD) for the endovascular treatment of direct carotid-cavernous sinus fistulae (diCCF). Methods Between 2011 and 2015, 14 consecutive patients with 14 diCCF were treated with FD alone or in combination with other implants in a single institution. Results A total of 21 sessions were performed in 14 patients. FD placement was technically successful in all cases without an adverse event. Patients were treated with FD alone (n = 5), FD and covered stents (n = 2), FD and coils (n = 7). A total of 59 FD (24 Pipeline Embolization Device, Medtronic; 35 p64 Flow Modulation Device, phenox), 291 coils, and 3 stent grafts were used. Three of 14 diCCF were completely occluded after the 1st session, a minor residual shunt was found in 7/14, and in the remaining 4/14 patients, the shunt volume was reduced significantly. The mean follow-up period encompassed 20 months. Additional treatment included transvenous coil occlusion (n = 3) and/or further FD deployment (n = 5). An asymptomatic internal carotid artery (ICA) occlusion was encountered in 2 patients, related to an interruption of antiaggregation. At the last follow-up, 10/14 patients were free from ocular symptoms (71 %), 2 had residual exophthalmos, and no patient had clinical deterioration. Conclusion The usage of FD for the treatment of diCCF is straightforward. Injury of the cranial nerves can be avoided. In most cases, ocular symptoms improve. Several FD layers and/or an adjunctive venous coil occlusion are required. Complete occlusion of a diCCF may take weeks or months and long-term antiaggregation is required. In the future, a flexible stent graft might be a better solution.
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Affiliation(s)
- C M Wendl
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany. .,Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Universitätsklinikum Regensburg, Regensburg, Germany.
| | - H Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.,Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
| | - R Martinez Moreno
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - H Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
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27
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Murthy SB, Shah J, Mangat HS, Stieg P. Treatment of Intracranial Aneurysms With Pipeline Embolization Device: Newer Applications and Technical Advances. Curr Treat Options Neurol 2016; 18:16. [PMID: 26923606 DOI: 10.1007/s11940-016-0399-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OPINION STATEMENT Pipeline embolization device (PED) is a flow diverter used in the endovascular treatment of intracranial aneurysms, particularly those with unfavorable configurations. It works by causing progressive flow redirection leading to thrombosis within the aneurysm. PED was initially approved for adults with large or giant wide-necked (≥4 mm or no discernible neck) aneurysms of the internal carotid artery (ICA) from the petrous to the superior hypophyseal segments. Studies have shown a superior aneurysm occlusion rate of 85 % at 6 months for the PED and mortality ranging from 2.6 to 4 %. There appears to be a knowledge gap in terms of the duration of dual antiplatelet therapy and efficacy of assessing platelet inhibition. However, increasing operator experience and favorable longer-term outcome data have led to the exploration of PED for a wide array of off-label uses. Given the paucity of good-quality studies comparing PED with other endovascular/surgical treatment options, several multicenter randomized trials are currently underway to answer these important questions.
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Affiliation(s)
- Santosh B Murthy
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA. .,Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.
| | - Jharna Shah
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Halinder S Mangat
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA.,Department of Neurosurgery, Weill Cornell Medical College, New York, NY, USA
| | - Philip Stieg
- Department of Neurosurgery, Weill Cornell Medical College, New York, NY, USA
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