Reversal of blindness after transvenous embolization of a carotid-cavernous fistula: case report

Transvenous embolization of a carotid cavernous fistula complicated by a hematoma at the tentorial edge

Indirect (dural) carotid cavernous fistulae are generally treated by endovascular surgery primary transvenous embolization that is safe and effective. We describe here a case of a left indirect carotid cavernous fistula that presented with proptosis and eye redness. The patient underwent transvenous embolization of carotid cavernous sinus. The procedure was complicated by a haemorrhage from the cavernous sinus. The post procedural CT scan showed a haematoma at the tentorial edge. Precise diagnosis and prompt treatment could prevent severe complications.

Bilateral visual loss as a sole manifestation complicating carotid cavernous fistula

Visual loss is one of the ocular symptoms resulting from a carotid cavernous fistula (CCF), but has rarely been reported as the sole manifestation in CCF. Visual impairment is known to be associated with a poor outcome unless timely intervention is employed. Herein, the authors report a patient with bilateral rapid progressing visual loss as a sole manifestation in CCF. Vision was successfully restored by transarterial embolization. The authors discuss the necessity of urgent fistula obliteration in patients with visual loss.

Transvenous treatment of cranial dural arteriovenous fistulas with hydrogel coated coils

SUMMARY

Intracranial dural arteriovenous fistulas (DAVF) with cortical venous reflux may become symptomatic due to venous congestion or intracranial hemorrhage. Venous congestion in the orbit can also occur resulting in proptosis, chemosis, double vision and progressive visual loss. The transvenous approach has been used for selective disconnection of the venous drainage to eliminate the venous congestion and future risk of intracranial bleeding and/or neurological deficit. Hydrogel coated coils (Hydro- Coil(R)) expand after contact with blood causing the coils to swell up to five to 11 times a standard 10-system bare platinum coil. Due to this property, HydroCoils could have an advantage over platinum coils in the transvenous approach to embolization of DAVFs. Ten patients with symptomatic cranial DAVF underwent a transvenous embolization using HydroCoils as the only embolic agent or in a combination with bare platinum coils. The patients' characteristics, symptoms, angioarchitecture of the DAVF, treatment, complications and results were analyzed. All the treated DAVFs were disconnected at the end of the procedure. All the patients with orbital symptoms had complete or significant improvement. There were no periprocedural complications. Nine patients had radiological follow-up showing cure. HydroCoils can be used effectively and safely to treat intracranial DAVFs transvenously. The volume expansion of Hydrocoils may have significant advantage over bare platinum coils given the large venous spaces that need to be filled. The use of HydroCoils may decrease the procedure time and consequently reduce the radiation dose to the patient.

Targeted compartmental embolization of cavernous sinus dural arteriovenous fistulae using transfemoral medial and lateral facial vein approaches

There are multiple transvenous approaches for treatment of cavernous dural arteriovenous fistulae (DAVF). The choice of a specific route depends on the compartment of the cavernous sinus involved in the fistula and its venous drainage. We used two different facial vein approaches to treat patients with cavernous DAVF draining directly into the anterior compartment of the cavernous sinus and thence to the superior ophthalmic vein. Other transvenous routes to the sinus were not apparent. Embolization was targeted to the involved compartment with preservation of those not embolized. No major post-procedure ophthalmic venous engorgement occurred. We believe that ideal treatment of cavernous DAVF is targeted transvenous coil deposition, which necessitates detailed knowledge of the anatomy of the facial veins and cavernous sinus compartments.

Endovascular strategies for carotid cavernous and intracerebral dural arteriovenous fistulas

Interventional neuroradiology is a less invasive modality than open neurosurgery for the treatment of a wide range of neurovascular disorders. Refinements in technique and improvements in the design of microcatheters, guide wires, and embolic materials have yielded superior clinical outcomes and provided an impetus to treat more of these lesions endovascularly rather than surgically. Endovascular therapy is the standard of care for direct and indirect carotid artery cavernous sinus fistulas and may also be curative for dural arteriovenous fistulas (AVFs) in other locations.

The authors provide review of the clinical features, pathophysiology, and management of intracranial AVFs focusing on contemporary endovascular treatment options.