Traumatic Carotid Cavernous Fistula Accompanying Basilar Skull Fracture: a Study on the Incidence of Traumatic Carotid Cavernous Fistula in the Patients With Basilar Skull Fracture and the Prognostic Analysis About Traumatic Carotid Cavernous Fistula

Endovascular and medical management strategies for carotid-cavernous fistulas: A safety and efficacy analysis

BACKGROUND

Carotid-cavernous fistulas (CCFs) are complex arteriovenous shunting lesions of the cavernous sinus with diverse clinical presentations. This study aimed to analyze clinical outcomes and differentiate patients treated with conservative observation versus those needing endovascular intervention.

METHODS

A retrospective analysis of 84 patients with angiographically confirmed CCF was conducted from 2000 to 2022. Endovascular treatment decisions were made at the discretion of neurointerventionalists. Clinical and angiographic data were collected, including Barrow CCF classification and treatment outcomes.

RESULTS

Patients managed conservatively (n = 17) had longer symptom duration (165 vs 42 days) and more indirect CCF (100% vs 68%) compared to those treated with endovascular embolization (n = 67). High-risk clinical symptoms, including proptosis, diplopia, decreased visual acuity, and chemosis, were more common in the embolization group. Cortical venous reflux and ophthalmic venous reflux were more prevalent in the embolization group (39% and 91%, respectively). Overall, 31% of embolized CCFs required retreatment, mainly Barrow type D lesions (65%). Transvenous coil embolization was the primary technique used (78%), followed by feeder artery embolization (16%), and internal carotid artery flow diversion (8%).

CONCLUSION

In selected CCF patients without high-risk symptoms or angiographic features, conservative observation is a safe and effective alternative to endovascular embolization. High-risk symptoms and angiographic features favor endovascular intervention. Complications were rare, and most were transient, emphasizing the safety of endovascular management. Longitudinal angiographic and ophthalmologic surveillance is essential for monitoring fistula persistence or recurrence.

Clinical characteristics, angiographic findings and treatment outcomes of carotid cavernous fistula in Makassar, Indonesia: a single-centre experience

Background

Carotid cavernous fistula (CCF) is an abnormal arteriovenous shunt between the carotid artery or its branches, with the cavernous sinus. It is still common in developing countries, and is mostly due to traumatic origin. Endovascular treatment has emerged as the primary mode of treatment of CCF. This is the first study describing the clinical manifestation, angiographic characteristic, and the challenges we face in endovascular treatment of CCF cases in Makassar, Indonesia.

Results

This descriptive study was conducted between January 2019 to March 2022. We reviewed medical records and angiograms of all patients diagnosed with CCF at the Wahidin General Hospital, Makassar. Clinical manifestations, angiogram results, treatment, and outcome data were analyzed. A total of 23 patients were included in this study, with 17 (73.9%) direct CCF (Barrow type A) and 6 (26.1%) indirect CCF (Barrow type B, C, D). The mean age of patients were 32 years old. The three most common clinical manifestations were proptosis (n = 21, 91.3%), headache (n = 14, 60.8%), and chemosis (n = 14, 60.8%). The three most common drainage routes were via the superior ophthalmic vein (n = 23, 100%), inferior petrosal sinus (n = 12, 52.1%), and superficial middle cerebral vein (n = 6, 26.0%). All patients with direct CCF (n = 17) had endovascular treatment, resulting in 13 cases with complete occlusion (76.5%), 3 cases with incomplete occlusion (17.6%), and 1 (5.9%) procedure cancelled due to difficult navigation. Occlusion of fistula was best achieved with detachable coil, with a technical success rate of 90%. In indirect CCF (n = 6), 4 patients were treated conservatively and 2 with endovascular treatment, with complete occlusion in 2 patients.

Conclusions

Carotid cavernous fistula patients commonly presented with orbital symptoms, headache, or neuro-ophthalmologic signs. The most common drainage pattern is via anterior route. Posterior, superior and lateral drainage were not found in indirect CCF. Endovascular treatment is an effective method for fistula closure, especially in the case of direct fistula. Challenges in endovascular treatment are related to the anatomy of the fistula and cavernous sinus.

Stick a Needle in My Eye: A Case Report of Penetrating Needlefish Injury Causing Cavernous Sinus Thrombosis and Carotid Cavernous Fistula

While swimming in the ocean on vacation in Cuba, a previously healthy 17-year-old female was unexpectedly stabbed through her orbit and into her brain by a needlefish. This is a unique case of a penetrating injury causing orbital cellulitis, retro-orbital abscess, cerebral venous sinus thrombosis and carotid cavernous fistula. After initial management at a local emergency department, she was transferred to a tertiary care trauma centre where she was treated by a team of emergency, neurosurgery, stroke neurology, ophthalmology, neuroradiology and infectious disease physicians. The patient faced a significant risk of a thrombotic event. There was careful consideration from the multidisciplinary team about the utility of thrombolysis or an interventional neuroradiology procedure. Ultimately, the patient was treated conservatively with intravenous antibiotics, low molecular weight heparin and observation. The patient continued to show clinical improvement several months later, which supported the challenging decision to opt for conservative management. There are very few cases to guide the treatment of this type of contaminated penetrating orbital and brain injury.

Traumatic intracranial aneurysms (TICA) in children: a description of two clinical cases of successful treatment and review of literature

OBJECTIVE

Traumatic intracranial aneurysms (TICA) across all age groups make up less than 1% of all aneurysms. Traumatic aneurysms in children occur from 10 to 39%, and their treatment requires special considerations. Even though readily diagnosed, the management of traumatic intracranial aneurysms in children is still a subject for discussion. Two cases of traumatic aneurysms following penetrating and blunt trauma are presented.

CASE DESCRIPTION

Two cases of traumatic aneurysms are presented. The first patient presented with an aneurysm of the distal M4 segment of the left middle cerebral artery (MCA) 1 week following blunt traumatic brain injury with skull fractures. The aneurysm was excised without complications. The second patient presented with a saccular aneurysm of the A2 segment of the left anterior cerebral artery (ACA) following penetrating traumatic brain injury with a metal rod. The aneurysm was discovered incidentally on computed tomography angiography (CTA) performed to exclude a brain abscess when the patient developed a persistent fever. After numerous unsuccessful attempts at endovascular embolization, microsurgical aneurysm clipping was performed without complications.

CONCLUSION

Traumatic intracerebral aneurysms are relatively more common in childhood. They commonly occur in the first 21 days post-trauma but can also occur in the late period. We, therefore, recommend that CTA or direct cerebral angiography should be performed within the first 3 weeks to exclude TICA and in all patients with sudden deterioration in the early postoperative period. Considering the high mortality rate associated with conservative management, surgical and/or endovascular management should be performed once the diagnosis is made.

Case Report: Management of Traumatic Carotid-Cavernous Fistulas in the Acute Setting of Penetrating Brain Injury

Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options.

First line Treatment of Traumatic Carotid Cavernous Fistulas Using Covered Stents at Level 1 Regional Trauma Center

Objective

The widely accepted treatment option of a traumatic carotid cavernous fistula (TCCF) has been detachable balloon or coils based fistula occlusion. Recently, covered stent implantation has been proving an excellent results. The purpose of this study is to investigate our experiences with first line choice of covered stent implantation for TCCF at level 1 regional trauma center.

Methods

From November 2004 to February 2020, 19 covered stents were used for treatment of 19 TCCF patients. Among them, 15 cases were first line treatment using covered stents. Clinical and angiographic data were retrospectively reviewed.

Results

Procedures were technically successful in all 15 cases (100%). Immediate angiographic results after procedure were total occlusion in 12 patients (80%). All patients except two expired patients had image follow-up (mean 15 months). Recurred symptomatic three patients underwent additional treatments and achieved complete occlusion. Mean clinical follow-up duration was 32 months and results were modified Rankin Scale 1–2 in five, 3–4 in five, and 5 in three patients.

Conclusion

The covered stent could be considered as fist line treatment option for treating TCCF patients especially in unstable vital sign. Larger samples and expanded follow-up are required to further develop their specifications and indications.

Post-traumatic carotid cavernous fistula: A case report

A carotid cavernous fistula is an abnormal connection between the carotid artery and cavernous sinus which is a rare and sight threatening complication of craniofacial trauma. We report a case of a 36-year-old man with history of road traffic accident, flail chest, on mechanical ventilation who developed redness and progressive swelling of right eye. On evaluation, he was found to have right-sided conjunctival chemosis, pulsatile proptosis, and loud bruit on auscultation over right eyeball. Non-contrast computed tomography revealed multiple skull bone fractures with prominence of right-sided cavernous sinus and superior ophthalmic vein. Contrast enhanced magnetic resonance imaging with angiography revealed bulky cavernous sinus with tortuous right superior ophthalmic vein suggestive of right carotid cavernous fistula. Carotid cavernous fistula should be considered as a differential diagnosis for a critically ill patient with history of trauma developing swollen red eyes as the typical signs and symptoms cannot be assessed in patients on mechanical ventilation. The timely diagnosis and prompt treatment can save vision and can improve the outcome.

Treatment of a rare and complex carotid-cavernous fistula

Carotid-cavernous fistulas (CCFs) are abnormal connections between arteries and the cavernous sinuses. Traditionally, the Barrow Classification system has been used to characterise these fistulas based on their arterial supply from the internal carotid artery (ICA), external carotid artery (ECA) or both. We present a unique case of a patient with a complex CCF with arterial feeders from dural branches of the ECA, ICA and vertebral artery (VA), which, to our knowledge, has not been reported in the literature. Given unique arterial supply pattern involving contribution from the extracranial VA, this CCF falls outside of the traditional Barrow Classification system. The patient ultimately underwent a transfemoral transvenous coil embolisation using multiple dynamic venous routes with obliteration of bilateral CCFs and near complete resolution of her preoperative symptoms.

Carotid-cavernous fistula from the perspective of an ophthalmologist A Review

Carotid-cavernous fistula (CCF) is an abnormal communication - vascular connection between arteries and veins in the cavernous sinus. Classification according to etiology is traumatic vs spontaneous. According to blood flow rate per high flow vs low flow fistula. According to anatomy of direct vs indirect: Direct (direct) CCF arises through direct communication between the internal carotid artery (ICA) and the cavernous sinus. Indirect CCF originates through indirect communication through the meningeal branches of ICA, external carotid artery and cavernous sinus (not directly with ICA) and Barrow type A, B, C, D division. Patients subjective complaints depend on the type of CCF. Most often it is pulsating tinnitus, synchronous with blood pulse. Typical findings include protrusion and pulsation of the eyeball, corkscrew vessels - arterialization of conjunctival and episleral vessels, increased intraocular pressure, not responding to local antiglaucomatous therapy, keratopathy a lagophthalmo, corneal ulcers. In the later untreated stages of CCF, secondary, venous stasis or central retinal vein occlusion can occur. Diagnostic procedures include B-scan and color Doppler ultrasonography, digital ophthamodynamometry, computer tomography, nuclear magnetic resonance and digital subtraction angiography. CCF can simulate orbitopathy, conjunctivitis symptoms, carotid occlusion, scleritis or cavernous sinus thrombosis. The ophthalmologist should recognize and indicate the necessary examinations in a timely manner. The therapy is ophthalmological, neuroradiological, sterotactic, surgical and conservative.

Endovascular therapy of direct dural carotid cavernous fistulas - A therapy assessment study including long-term follow-up patient interviews

Purpose

Endovascular embolization nowadays is a well-established treatment option for direct carotid cavernous fistulas (dCCF, Barrow Type A). There are many publications on the complication and success rates of this method. However, little is known on the patients´ opinion on the treatment result after several years. We report on this issue also including the “pioneer patients” treated almost two decades ago.

Methods

We retrospectively reviewed the records of all patient (n = 25) with a more than 24 months follow-up interval after endovascular treatment of a dCCF at our institution from 01/1999 to 08/2018. We determined primary therapy success, complication rate, state of the fistula in the last imaging follow-up and quoted the patient’s subjective perception of the long-term treatment success using a standardized interview form.

Results

Occlusion rate in the last imaging follow up was 96% (24/25) with a complication rate of 8% (2/25). The response rate on our interview request was 96% (24/25) with a rate of considered feedback of 84% (21/25 patients). Duration of our observation interval for the patient reported outcome was 143 months / 11 years (median, range: 35–226 m / 2–18 y). Most of them (21/25, 84%) felt they benefited from the treatment.

Conclusions

Endovascular supply of dCCF is a highly effective treatment method leading to a sustainable therapy success with long-lasting stable subjective benefit even to our “pioneer patients” treated almost two decades ago.

Prediction of traumatic carotid-cavernous sinus fistula via noncontrast computed tomography by fracture pattern and abnormality of venous system

BACKGROUND

Traumatic carotid-cavernous sinus fistula (tCCF) is infrequent but with high morbidity if delayed diagnosed or managed. Because of the lack of screening criteria and requirement of advanced and invasive radiological examinations, diagnosis is often delayed or underdiagnosed.

METHODS

A matched case-control study with univariate and multivariate analyses was conducted to predict tCCFs. Forty-six patients diagnosed with tCCFs were included and matched with 138 patients of craniofacial trauma without tCCF as control at a ratio of 1:3.

RESULTS

The diagnostic diameter of superior ophthalmic vein (SOV) in tCCF was 4 mm with area under curve of 0.89. In multivariate analysis, engorgement of SOV and cavernous sinus (odds ratio [OR], 35.39; 95% confidence interval [CI], 13.56-104.84; p < 0.001) and lateral impact (ipsilateral temporal and sphenoid sinus fractures) (OR, 3.96; 95% CI, 1.10-14.91; p = 0.028) were identified significant, whereas basilar skull fracture (OR, 1.58; 95% CI, 0.53-4.75; p = 0.300) and injuries to ocular nerves (cranial nerves III, IV, and VI) (OR, 1.77; 95% CI, 0.38-7.88; p = 0.055) were insignificant.

CONCLUSION

Presence of SOV or cavernous sinus engorgement on noncontrast computed tomography and lateral impact were demonstrated as independent predictors to tCCF and warrant further radiological evaluation. Injury to ocular nerves is not predictive but as an essential differential diagnosis with reversible outcome.

LEVEL OF EVIDENCE

Diagnostic, level III.

Post-traumatic right carotid-cavernous fistula resulting in symptoms in the contralateral eye: a case report and literature review

Background

To report a case of a carotid-cavernous fistula (CCF) that occurred after a motor vehicle accident and review the uniqueness of this case and the main confusing points for the diagnosis of such cases.

Case presentation

A 22-year-old man complained of left eyelid swelling, eye redness, visual decrease and occasional headache after motor vehicle accident 4 months prior during which he experienced a head injury. He was initially thought to have glaucoma, but he was finally diagnosed with a right CCF based on magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). Timely embolization surgery resulted in obvious relief of the ocular symptoms and an improved prognosis.

Conclusion

This is the first reported case of a post-traumatic unilateral CCF with contralateral symptoms in direct CCF, it is very infrequent and deserves our attention. We should maintain high suspicion of CCF and confirm the diagnosis by DSA when managing such patients to prevent serious consequences. Early diagnosis and treatment can improve the prognosis of patients.

"Five-layer gasket seal" watertight closure for reconstruction of the skull base in complex bilateral traumatic intraorbital meningoencephaloceles: a case report and literature review

PURPOSE

Traumatic meningoencephalocele primarily occurs as a rare but complex complication of cranial base and orbital roof fractures. Traumatic intraorbital meningoencephalocele, which is rare and easily overlooked, can be life-threatening since cephalomeningitis occurs due to cerebrospinal fluid (CSF) leakage. It is obscure for the operative indications or standard surgical methods of traumatic meningoencephaloceles since the combined intricate craniofacial and basal fractures, brain injury, and CSF leak may exist. This case report proposes a new operative method for the repair of complex skull base fractures following traumatic intraorbital meningoencephalocele.

METHODS

A 30-year-old male with a history of complex trauma presented with symptoms of exophthalmos and traumatic CSF rhinorrhea was evaluated via 3D CT of the skull base and brain MRI and was diagnosed with bilateral intraorbital meningoencephaloceles and multiple craniofacial bone, skull base, and orbit fractures.

RESULTS

Successful resection of the meningoencephaloceles and reconstruction of the skull base defects were performed via craniotomy using a "five-layer gasket seal" technique that involved, from extracranial to intracranial, a gelatin sponge, muscular paste, vascularized periosteum, RapidSorb Orbital Floor Plate (OrbFloor), and Neuro-Patch layers.

CONCLUSIONS

The diagnosis and treatment of complex intraorbital meningoencephalocele require careful attention. Resection of herniated tissue is suggested due to potential contamination. The "five-layer gasket seal" watertight closure technique is recommended for successful repair of the skull base in cases involving traumatic meningoencephalocele with complex skull base fractures.

Vasospasm in the setting of traumatic bilateral carotid-cavernous fistulas and its effect on treatment

Background:

Direct, Type A, cavernous-carotid fistulas (CCFs) are predominantly caused by head trauma, especially when basilar skull fractures are present. Transarterial endovascular treatment of direct CCFs is the preferred method of treatment. Bilateral CCFs are estimated to be present in 1–2% of the cases. The treatment of bilateral CCFs is difficult often requiring a combination of endovascular and open surgical approaches.

Case Description:

We present a case of traumatic bilateral CCFs presenting with vasospasm of the anterior circulation seen on the initial angiogram on day 1 and our treatment paradigm.

Conclusion:

This case illustrates the challenges in managing bilateral CCFs as well as the changes in collateral circulation because of cerebral vasospasm which affected our treatment paradigm.

A Case of Right-Sided Direct Carotid Cavernous Fistula: A Diagnostic Challenge

Patient: Female, 83

Final Diagnosis: Right-sided direct carotid cavernous fistula

Symptoms: Chemosis • proptosis and eye pain

Medication: Topical α2-adrenergic agonist

Clinical Procedure: Endovascular embolization

Specialty: Internal Medicine • Interventional Radiology • Ophthalmology

A rare case report of complications in craniofacial injuries: Cavernous sinus-carotid fistula

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.

Bilateral carotid cavernous sinus fistula: a case report and review of the literature

Carotid cavernous fistula (CCF) is an abnormal vascular shunt from the carotid artery to the cavernous sinus. They are commonly classified based on hemodynamics, etiology or anatomically. Hemodynamic classification refers to whether the fistula is high or low flow. Etiology is commonly secondary to trauma or can occur spontaneously in the setting of aneurysm or medical conditions predisposing to arterial wall defects. Bilateral carotid cavernous fistulas are rare. We present a case of bilateral CCF secondary to trauma. Ophthalmology was urgently consulted to assess the patient in the intensive care unit (ICU) for red eye. The patient was found to have decreased vision, increased intraocular pressure, an afferent pupillary defect, proptosis, chemosis, and ophthalmoplegia. Subsequent neuro-imaging confirmed a bilateral CCF. The patient underwent two endovascular embolization procedures. Trauma is the most common cause of CCF and accounts for up to 75% of cases. Most common signs of CCF depend on whether it is high or low flow. High-flow CCF may present with chemosis, proptosis, cranial nerve palsy, increased intraocular pressure, diplopia, and decreased vision. Cerebral angiography is the gold standard diagnostic modality. First-line treatment consists of endovascular embolization with either a metallic coil, endovascular balloon or embolic agent. It is unclear in the literature if bilateral cases are more difficult to treat or have a different prognosis. Our patient required two endovascular procedures suggesting that endovascular intervention may have reduced efficacy in bilateral cases.

Traumatic Carotid Cavernous Fistula with a Connection between the Supraclinoid Internal Carotid Artery and Cavernous Sinus via a Pseudoaneurysm Presenting with Delayed Life-threatening Epistaxis

Traumatic carotid cavernous fistula (CCF) presents most commonly as a direct connection between the cavernous segment of internal carotid artery (ICA) and cavernous sinus (CS), and often accompanies basal skull fracture (BSF). The most frequently reported signs and symptoms are proptosis, chemosis, and bruit. Epistaxis is uncommon symptom of CCF. A 63-year-old man with a history of BSF due to blunt head trauma eight months previously was referred to our emergency room for massive epistaxis. Cerebral angiography demonstrated a high-flow CCF with a connection between the supraclinoid portion of left ICA and CS via a pseudoaneurysm, suggesting the life-threatening epistaxis had been caused by high-flow shunting, through the gap created by the BSF. After the complete obliteration of the pseudoaneurysm arising from the supraclinoid ICA by stent-assisted coil embolization, the CCF was no longer evident and epistaxis ceased. To the best of our knowledge, this is the first case of a traumatic CCF with a connection between the supraclinoid ICA and CS via a pseudoaneurysm, presenting with delayed life-threatening epistaxis.

Basic Imaging of Skull Base Trauma

Skull base fractures extend through the floor of the anterior, middle, or posterior cranial fossa. They are frequently associated with complex facial fractures and serious complications such as cranial nerve or vascular injury, cerebrospinal fluid leak, or meningitis. Several distinct patterns of skull base fractures have been recognized, each of them associated with different complications. Recognition of, often subtle, skull base fracture is essential to prevent or allow early treatment of these serious complications.

Interdisciplinary Management of Minimally Displaced Orbital Roof Fractures: Delayed Pulsatile Exophthalmos and Orbital Encephalocele

Traumatic orbital roof fractures are rare and are managed nonoperatively in most cases. They are typically associated with severe mechanisms of injury and may be associated with significant neurologic or ophthalmologic compromise including traumatic brain injury and vision loss. Rarely, traumatic encephalocele or pulsatile exophthalmos may be present at the time of injury or develop in delayed fashion, necessitating close observation of these patients. In this article, we describe two patients with minimally displaced blow-in type orbital roof fractures that were later complicated by orbital encephalocele and pulsatile exophthalmos, prompting urgent surgical intervention. We also suggest a management algorithm for adult patients with orbital roof fractures, emphasizing careful observation and interdisciplinary management involving plastic surgery, neurosurgery, and ophthalmology.

Traumatic posterior communicating artery-cavernous fistula, angioarchitecture, and possible pathogenesis: a case report and literature review

Carotid-cavernous fistulas (CCFs) are an abnormal vascular shunt between the carotid artery and the cavernous sinus, and were traditionally classified into four subtypes based on the detailed fistulas anatomy and arterial supply. CCFs are frequently encountered in patients with traumatic skull base fractures. In this report, we present one such case caused by two head traumas. Computed tomography and digital subtraction angiography confirmed that this CCF arose from posterior communicating artery of the internal carotid artery, which is not included in the traditional Barrow et al's categorization. The possible mechanisms include laceration of dural mater of posterior clinoid process and laceration or pseudoaneurysm formation of posterior communicating artery. This case was successfully treated with endovascular coil embolization.

Mid- and long-term outcomes of carotid-cavernous fistula endovascular management with Onyx and n-BCA: experience of a single tertiary center

INTRODUCTION

Endovascular therapy is the preferred treatment for most carotid-cavernous fistulas (CCFs). Early reports have documented excellent initial clinical and radiographic outcomes after embolization of CCFs with Onyx or n-butyl cyanoacrylate (n-BCA), but little evidence is available about the long-term durability of this technique.

OBJECTIVE

To characterize the long-term durability of CCF liquid embolization.

METHODS

The authors retrospectively reviewed a database of 24 CCFs in 21 consecutive patients who underwent Onyx or n-BCA embolization of a CCF from 2006 to 2013 at our institution.

RESULTS

A total of 25 Onyx or n-BCA embolization procedures were attempted and 24 successfully completed during the study, resulting in complete or near-complete occlusion by the end of the study in all 24 CCFs (obliteration success, 100%). Attempted embolization in a single CCF failed initially, but was performed successfully at a later date by a different approach. None of the 24 CCFs recanalized, regrew, or required any further treatment subsequent to Onyx or n-BCA embolization throughout a mean 12.4 months of angiographic follow-up (range 1-36 months). Clinically significant complications were seen in three embolization procedures, including cranial nerve palsies (n=1), embolic infarct (n=1), and intraperitoneal hemorrhage (n=1).

CONCLUSIONS

Early evidence has indicated that endovascular embolization with Onyx is relatively safe and effective at achieving an initial angiographic cure for CCFs. Results of our series suggest that angiographic and clinical outcomes of Onyx and n-BCA embolization remain stable at mid- and long-term follow-up.

Endovascular treatment in an unusual case of direct carotid cavernous fistula

We describe a unique and unusual case of post-traumatic direct carotid cavernous fistula (CCF) with occluded proximal internal carotid artery and CCF filling from the contralateral side with retrograde cortical venous reflux. A male patient presented with intracranial haemorrhage due to cortical venous reflux. He was treated endovascularly through a contralateral approach by coiling the cavernous sinus and occluding the distal internal carotid artery at the fistulous site with glue.

Spontaneous carotid-cavernous fistula: challenges in clinical and radiologic diagnosis

We present a 47-year-old female patient with spontaneous carotid-cavernous fistula without comorbidities. The symptoms of a carotid-cavernous fistula may be confused with other pathology in the region of the orbit and cavernous sinus such as cavernous sinus thrombosis. Carotid-cavernous fistulas most commonly result from direct injury to the internal carotid artery, as with skull base or surgical trauma, but it can also result from weakness in the arterial wall, as with an aneurysm. Because of the high flow of the internal carotid artery, carotid-cavernous fistulas typically present with rapidly progressive symptoms. The case study presented demonstrates the usefulness of radiologic studies in distinguishing between these similarly presenting disease processes. Clinically, cavernous sinus thrombosis generally presents bilaterally and carotid-cavernous fistula presents unilaterally; however, there are a number of exceptions in the literature. The use of a variety of radiologic and angiographic studies will help differentiate between these pathologies. On magnetic resonance imaging, both pathologies can appear as an enlargement of cavernous sinus. Magnetic resonance angiography sequence can reveal aneurysms communicating with the cavernous sinus, and magnetic resonance venography will define thrombosis within the cavernous sinus. Differentiating between cavernous sinus thrombosis and carotid-cavernous fistula can be clinically difficult, and a team approach including emergency physicians, neurosurgeons, ophthalmologists, and otolaryngologists will be called upon to assist in diagnosis. Prompt diagnosis and management can allow for potentially vision and lifesaving interventions.

Traumatic carotid-cavernous fistula at the anterior ascending segment of the internal carotid artery in a pediatric patient

INTRODUCTION

Traumatic carotid-cavernous fistula (CCF) in children is a rare condition. Early diagnosis and treatment is still a challenge, and it is associated with good neurological recovery.

CASE SUMMARY

We present a rare case of a 10-year-old boy with mild head trauma, who developed a CCF at the anterior segment of the ascending internal carotid artery. The patient was treated with endovascular coil embolization and evolved with a favorable outcome.

DISCUSSION

Most of reports in the literature address the traumatic CCF in adult patients, in which early treatment may prevent poor recovery or fatal outcomes. The diagnosis and management of this condition are discussed based on a literature review.

CONCLUSION

It is important to keep a high degree of suspicion for CCF, especially in traumatic head injury associated with skull base fracture, since the early diagnosis and treatment may prevent potentially permanent neurological deficits.

Traumatic carotid-cavernous fistula presenting as massive epistaxis

Carotid-cavernous sinus fistulae (CCF) are a rare complication with the potential for great morbidity including intracranial hemorrhage, blindness, cranial nerve palsy and stroke. Traumatic CCF are the most common type of CCF. Here we discuss a patient who sustained blunt head trauma and had substantial epistaxis, requiring massive transfusion, intraoperatively due to unrecognized CCF.

Carotid-cavernous fistulas

Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.

Classification and prediction of outcome in traumatic brain injury based on computed tomographic imaging

Traumatic brain injury (TBI) is a common and potentially devastating problem. The classification of TBI is necessary for accurate diagnosis and the prediction of outcomes. The increased use of early sedation, intubation and ventilation in more severely injured patients has decreased the value of the Glasgow Coma Scale for the purposes of classification. An alternative is the classification of TBI according to morphological criteria based on computed tomography (CT) investigations. This article reviews the current classification and prediction of outcomes in TBI based on CT imaging. Classifications based on the presence or absence of intracranial local lesions, diffuse injury, signs of subarachnoid or intra-ventricular haemorrhage and fractures or foreign bodies are considered, and their predictive value is discussed. Future studies should address the complicated issue of how optimally to combine CT characteristics for prognostic purposes and how to improve on currently used CT classifications to predict outcomes more accurately.

Etiology of carotid cavernous fistula in Japanese

BACKGROUND

A carotid cavernous fistula (CCF) develops spontaneously or after trauma, and older publications suggest that the majority of CCF cases are caused by trauma. However, more recent reports question the prevalence of CCFs caused by trauma.

METHODS

The clinical records of 37 consecutive patients diagnosed with a CCF were reviewed. The disease etiology, patient demographics, anatomical classification, and clinical course were investigated.

RESULTS

The CCF was spontaneous in 30 patients, and was related to head or neck trauma in seven patients. The mean age of all patients was 65.8 +/- 10.5 years, and 30 (81.1%) were women. Eight had diabetes and 14 had hypertension. The major signs and symptoms were congestion (86.4%), diplopia (81.1%), bruit (59.5%), and headaches/orbital pain (62.2%). Exophthalmos (67.6%) and elevated intraocular pressure (40.5%) were also frequently noted. In the Barrow classification, seven patients were classified as type A, four as type B, three as type C, and 20 as type D. The classification could not be established in three patients who did not undergo angiography. Of note, almost all patients had consulted an ophthalmologist before the diagnosis.

CONCLUSION

Spontaneous/low-flow CCF is more prevalent than previously reported. The role of ophthalmologists is important because the majority of patients initially consult ophthalmologists, and the signs of low-flow CCF are subtle and may be overlooked.

Interventional radiology in the treatment of intracranial vascular injuries and fistulae

Traumatic intracranial vascular injuries are uncommon. However prompt diagnosis and management is essential because of the high morbidity and mortality associated with these conditions. The imaging evaluation and potential endovascular management of traumatic intracranial aneurysms and traumatic intracranial fistulae is discussed.