Management of Iatrogenic Direct Carotid Cavernous Fistula Occurring During Endovascular Treatment of Stroke

Delayed Iatrogenic Direct Carotid Cavernous Fistula Following Flow Diversion for Aneurysm With Spontaneous Healing: A Case Report

An abnormal connection between the carotid artery and cavernous sinus is referred to as a carotid cavernous fistula (CCF). A direct CCF results when the connection occurs between the intracranial internal carotid artery (ICA) and the cavernous sinus. These events are typically the result of a head injury, but can also be iatrogenic, resulting from various intracranial procedures. Direct CCF occurrences rarely heal spontaneously due to the high flow rate across the fistula. In this report, we present an uncommon case involving a delayed iatrogenic direct CCF, which developed following the placement of a pipeline flow-diverting stent that was used to treat a cerebral aneurysm. Interestingly, this unusual iatrogenic direct CCF subsequently spontaneously resolved within a few months. To our knowledge, this is the only case of a delayed CCF occurring with the use of a flow-diverting sent, which then resolved on its own. This report recounts our experience with the case.

Carotid-cavernous fistula following mechanical thrombectomy of the tortuous internal carotid artery: A case report

BACKGROUND

A carotid-cavernous fistula (CCF) is an abnormal connection between the internal carotid artery (ICA) and the cavernous sinus. Although direct CCFs typically result from trauma or as an iatrogenic complication of neuroendovascular procedures, they can occur as surgery-related complications after mechanical thrombectomy (MT). With the widespread use of MT in patients with acute ischemic stroke complicated with large vessel occlusion, it is important to document CCF following MT and how to avoid them. In this study, we present a case of a patient who developed a CCF following MT and describe in detail the characteristics of ICA tortuosity in this case.

CASE SUMMARY

A 60-year-old woman experienced weakness in the left upper and lower limbs as well as difficulty speaking for 4 h. The neurological examination revealed left central facial paralysis and left hemiplegia, with a National Institutes of Health Stroke Scale score of 9. Head magnetic resonance imaging revealed an acute cerebral infarction in the right basal ganglia and radial crown. Magnetic resonance angiography demonstrated an occlusion of the right ICA and middle cerebral artery. Digital subtraction angiography demonstrated distal occlusion of the cervical segment of the right ICA. We performed suction combined with stent thrombectomy. Then, postoperative angiography was performed, which showed a right CCF. One month later, CCF embolization was performed, and the patient's clinical symptoms have significantly improved 5 mo after the operation.

CONCLUSION

Although a CCF is a rare complication after MT, it should be considered. Understanding the tortuosity of the internal carotid-cavernous sinus may help predict the complexity of MT and avoid this complication.

Direct Carotid-Cavernous Fistula Caused by Internal Carotid Artery Perforation by a Microcatheter Body during Mechanical Thrombectomy

Rapid advances in emergent mechanical thrombectomy have resulted in a higher occurrence of arterial perforations during neurointerventions. Here, we report a case of internal carotid artery (ICA) perforation during mechanical thrombectomy in a 78-year-old man with a left middle cerebral artery occlusion. The ICA was perforated by a microcatheter during thrombectomy, forming a direct carotid-cavernous fistula. A two-stage drainer occlusion was conducted because of cortical venous reflex aggravation and ocular symptoms. Here, we report the perforation details and treatment, adding to evidence that ICA perforation with the microcatheter body is a concern during mechanical thrombectomy.

Carotid-cavernous sinus fistula following mechanical thrombectomy in acute ischaemic stroke: a rare complication

Carotid-cavernous sinus fistulas (CCFs) are abnormal communications between the internal carotid artery (ICA) and the cavernous sinus (CS). Direct CCFs are associated with trauma or are iatrogenic complications of neuroendovascular procedures. Meanwhile, mechanical endovascular thrombectomy (MT) in acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO) has been established as a common treatment approach. However, MT is not without its risks of complications, and only a few reports exist on CCF occurring after MT. Here, we present a case of a 63-year-old patient with iatrogenic high-flow CCF of the right horizontal cavernous ICA segment (C4) following repeated MT due to LVO of the middle cerebral artery, and the recent literature is reviewed.

Carotid cavernous fistula (CCF) treatment approaches: A systematic literature review and meta-analysis of transarterial and transvenous embolization for direct and indirect CCFs

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.

Carotid Cavernous Fistula during Thrombectomy for Acute Ischemic Stroke: A Case Report

Objective

We report a rare complication, carotid cavernous fistula (CCF), due to vessel perforation during thrombectomy for acute ischemic stroke (AIS).

Case Presentation

An 88-year-old woman underwent thrombectomy for left C4 occlusion of the internal carotid artery. There was strong resistance at the medial C4 while the microguidewire was guided distally, and a CCF was found after deploying and retrieving the stent. It was thought to have been caused by perforation due to intracranial atherosclerotic stenosis of the internal carotid artery.

Conclusion

During thrombectomy for intracranial large vessel occlusion underlying intracranial atherosclerotic stenosis, the risk of vascular injury should be kept in mind.

Exophthalmos following mechanical thrombectomy for anterior circulation stroke: A retrospective study and review of literature

BACKGROUND

Anecdotal cases of exophthalmos after acute mechanical thrombectomy have been described. We sought to estimate the incidence in a large cohort of patients with acute anterior circulation stroke treated with mechanical thrombectomy. Secondarily, we aimed to evaluate the underlying mechanism and to differentiate it on imaging from other pathology with similar clinical orbital features.

METHODS

Between November 2016 and November 2018, we performed a retrospective single-center study of 250 patients who underwent anterior circulation mechanical thrombectomy. Development of exophthalmos was independently evaluated by two readers on preprocedure and 24-h postprocedure non-contrast cerebral CT.

RESULTS

In the mechanical thrombectomy cohort, six individuals (2.4%) developed interval ipsilateral exophthalmos at 24 h. Of these, at least two patients developed clinical symptoms. There was almost perfect agreement between assessments of the two readers (Cohen's kappa = 0.907 (95% confidence interval: 0.726, 1.000)). In two patients, there was delayed ophthalmic artery filling on digital subtraction angiography. None of the patients had features of a direct carotid-cavernous fistula.

CONCLUSIONS

Exophthalmos is not uncommon after mechanical thrombectomy (2.4%). The underlying mechanism is difficult to confirm, but it is most likely due to orbital ischemia from hypoperfusion or distal emboli.

Iatrogenic Direct Carotid-cavernous Fistula Following Mechanical Thrombectomy: A Case Report and Review of the Literature

A carotid-cavernous fistula (CCF) is an abnormal connection between the arteries and veins of the cavernous sinus. Iatrogenic CCFs have been described as potential complications following aneurysm coiling, balloon angioplasty, and transsphenoidal surgery. In this case report, we describe a rare case of an iatrogenic direct CCF following mechanical thrombectomy (MT) for acute ischemic stroke. A 78-year-old female presented to an outside hospital with a new onset of right-sided weakness and aphasia and underwent emergency MT for a left middle cerebral artery (MCA) occlusion. The procedure was complicated by iatrogenic injury to the left cavernous internal carotid artery (ICA), which resulted in a direct high-flow CCF. The patient was transferred to our hospital and the fistula was closed with transarterial coils. Ten days later, she returned with diplopia and cranial nerve VI palsy due to residual pseudoaneurysm and was treated with a flow-diverting stent. On follow-up, the patient was neurologically intact and imaging showed no residual fistula. As the frequency of MTs performed for acute ischemic stroke continues to rise, neurointerventionalists should be aware of this potential rare complication and be prepared to manage patients who develop symptomatic CCF.

Dissection-related carotid-cavernous fistula (CCF) following surgical revascularization of chronic internal carotid artery occlusion: a new subtype of CCF and proposed management

BACKGROUND

The development of carotid-cavernous fistulas (CCFs) during surgical recanalization of chronic internal carotid artery occlusion (ICAO) may be secondary to severe ICA dissection rather than a focal tear of the cavernous ICA seen in typical traumatic CCFs. The purpose of this study is to investigate the causal relationship between the CCFs and severe ICA dissections and to characterize technical outcomes after treatment with stenting.

METHODS

Five patients underwent treatment with self-expanding stents due to intraprocedural CCF and ICA dissection following surgical removal of ICAO plaque. The stents were telescopically placed via true channel of the dissection. Safety of the procedure was evaluated with 30-day stroke and death rate. Procedural success was determined by the efficacy of CCF obliteration and ICAO recanalization with angiography.

RESULTS

All CCFs were associated with spiral and long segmental dissection from the cervical to cavernous ICA. After stenting, successful dissection reconstruction with TICI 3 was achieved in all patients, with complete (n = 4) or partial CCF (n = 1) obliteration. No patient had CCF syndrome, stroke, or death during follow-up of 6 to 37 months; but one patient had pulsatile tinnitus, which resolved 1 year later. Angiography at 6 to 24 months demonstrated CCF obliteration in all 5 patients and durable ICA patency in 4 patients.

CONCLUSIONS

Intraprocedural CCFs with spiral and cervical-to-cavernous ICA dissection during ICAO surgery are dissection-related because of successful obliteration after stenting for dissection reconstruction. Self-expanding stenting through true channel of the dissection, serving as implanting stent-autograft, may be an optimal therapy for the atypical CCF complication from ICAO surgery.

Direct Aspiration Catheter Fracture and Retrieval during Neurothrombectomy

Background

Application of direct aspiration catheters has revolutionized acute stroke care and has led to significant improvement in clinical outcome with a good safety profile. Catheter fracture and retention is a rare but potentially devastating complication.

Case Description

Here we present two cases of acute stroke complicated by aspiration catheter fracture and retention. Successful catheter retrieval and revascularization was achieved in both cases. The stenosis or tortuosity of vascular anatomy appears to be the probable contributor to catheter breakage by anchoring the catheter with resultant fracture at the constraint point from catheter withdrawal tensile stress.

Conclusion

This report describes application of snare devices in retrieving a broken catheter during thrombectomy in the anterior and posterior circulation, and therefore presents a technique that can be safely utilized to address catheter breakage complicating thrombectomy in different vascular anatomic locations.