Flow diversion in the treatment of carotid injury and carotid-cavernous fistula after transsphenoidal surgery

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.

Internal carotid artery injury during endoscopic transsphenoidal pituitary surgery: risk factors, management

BACKGROUND

Transsphenoidal surgeons should try to avoid internal carotid artery (ICA) injury but also be prepared to manage it. We analyzed our experience with ICA injury during endoscopic transsphenoidal pituitary surgery and present associated risk factors and a management protocol.

METHODS

We retrospectively reviewed and analyzed the medical records of 1596 patients who underwent endoscopic transsphenoidal surgery for pituitary tumor resection in our institution from January 2009 to October 2022.

RESULTS

Six patients experienced an ICA injury. All received timely and effective hemostasis with immediate direct tamponade followed by endovascular treatment. No serious postoperative complications occurred.

CONCLUSIONS

We proposed a treatment plan for ICA injuries encountered during endoscopic transsphenoidal surgery and described our hemostasis process, methods of endovascular treatment, and means of postoperative follow-up in detail.

Interventional treatment of traumatic carotid-cavernous fistula: A case report

RATIONALE

Patients with traumatic carotid-cavernous fistula (TCCF) usually go to the ophthalmology department first because of the symptoms such as protrusion of eyes, edema and congestion of combined membrane, vision loss and so on. It is easy to be misdiagnosed and missed.

PATIENT CONCERNS

We report a case of left eye swelling and vision loss caused by TCCF after head injury due to traffic accident, which failed to respond to ophthalmic treatment for many times. The similar situation is very likely to cause panic among patients.

DIAGNOSIS

Cerebral angiography revealed left internal carotid-cavernous fistula (high flow type).

INTERVENTIONS

Left internal carotid artery covered stent implantation was performed.

OUTCOMES

The fistulas and the original venous mass were completely covered by the covered stent, and the development of the vascular mass disappeared. The patient's eye symptoms basically disappeared 14 days after the operation.

LESSONS

Interventional treatment of TCCF is effective.

An Institutional Experience and Literature Review on Iatrogenic Major Vascular Injury in Neurosurgery: Proposal of a Management Algorithm

Background

Major vessel injury is among the most dreaded complications of any neurosurgical procedure. Once intraoperatively tamponaded, it can present in the form of pseudoaneurysm, dissecting aneurysm or complete occlusion of vessel. These injuries are often associated with very high morbidity and mortality. The literature available on this topic is limited and our understanding remains limited.

Objective

In this article, we present our surgical experience with iatrogenic aneurysms and present a review of literature.

Methods and Material

We conducted a retrospective analysis of all patients with major vessel injury during surgery from a prospectively maintained database from January 2012 to February 2020.

Results

A total of 15 patients developed iatrogenic aneurysms following a major vessel injury during various neurosurgical procedures. The most common vessel injured was vertebral artery (n = 9) in craniovertebral junction (CVJ) anomalies and ossification of posterior longitudinal ligament (OPLL) followed by internal carotid artery injury (n = 5) in sellar and parasellar pathologies. One patient developed basilar artery injury during endoscopic third ventriculostomy (ETV). Eight patients had pseudoaneurysm and seven had dissecting aneurysm with or without complete thrombosis of the involved artery. A total of two patients died after vascular injury and remaining thirteen patients survived and discharged.

Conclusions

The adage "prevention is better than cure" applies most aptly in such cases. Any major vessel injury should be followed by immediate angiography and subsequent early management. The endovascular management is more favorable as these aneurysms are difficult to clip due to the absence of a neck and fragile wall.

Treatment of carotid cavernous sinus fistulas with flow diverters. A case report and systematic review

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.

Surgery for acromegaly: Indications and goals

Acromegaly is a disease that occurs secondary to high levels of GH, most often from a hormone-secreting pituitary adenoma, with multisystem adverse effects. Diagnosis includes serum GH and IGF-1 levels, and obtaining an MRI pituitary protocol to assess for a functional pituitary adenoma. Attempted gross total resection of the GH-secreting adenoma is the gold standard in treatment for patients with acromegaly for a goal of biochemical remission. Medical and radiation therapies are available when patients do not achieve biochemical cure after surgical therapy.

Balloon-Assisted Roadmap Technique to Enable Flow Diversion of a High-Flow Direct Carotid-Cavernous Fistula

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.

Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience

Background and objective

To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach.

Methods

We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative “sandwich technique” combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed.

Results

No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus.

Conclusions

Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding.

Treatment of post-traumatic direct carotid-cavernous fistulas using flow diverting stents: Is it alone satisfactory?

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).

Carotid Cavernous Fistula Treatment via Flow Diversion: A Systematic Review of the Literature

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.

Endovascular reconstruction of iatrogenic internal carotid artery injury following endonasal surgery: a systematic review

The objective of this study is to provide an update on endovascular treatments for iatrogenic internal carotid artery (ICA) injuries following endonasal surgery. A systematic review of the literature was performed by using Medline, Cochrane library, and Scopus from 1999 to 2019. We used a combination of the MeSH terms "internal carotid artery," "iatrogenic disease," and "endovascular procedure." Twenty-six articles including 46 patients were identified for in this systematic review. The mean age of the patients was 49 years (CI: ± 4.2). The most common site of ICA injury was in cavernous segment (18 patients; 39%). The most common type of iatrogenic ICA injury was a traumatic pseudoaneurysm documented in 28 patients (60%). Endoluminal reconstruction was performed using covered stents in 28 patients, the Pipeline embolization device (PED) in 13 patients, the Surpass flow diverter device in three, the SILK flow diverter in one, and one case was treated using a combined approach of a covered stent and a PED. Flow diversion and covered stents resulted in a good clinical outcome in 94% and 89% of patients, respectively. This difference did not reach statistical significance (p = 1.0). Even though this systematic review was limited due to articles of small sample sizes and considerable heterogeneity, the results indicate that flow diverting devices and covered stents are good therapeutic options for endoluminal reconstruction of iatrogenic ICA injuries following endonasal surgery.

Pipeline embolization for an iatrogenic intracranial internal carotid artery pseudoaneurysm after transsphenoidal pituitary tumor surgery: Case report and review of the literature

Intracranial pseudoaneurysms are uncommon and among the most difficult lesions to treat with surgery or endovascular means without parent artery sacrifice. Here, we report on a patient who underwent successful treatment using a flow-diverting stent for an iatrogenic intracranial internal carotid artery pseudoaneurysm following a vessel injury after endoscopic pituitary tumor resection via the transsphenoidal approach. A 62-year-old man with a Rathke's cleft cyst presenting with bitemporal hemianopia and progressive decline of left visual acuity underwent endoscopic transsphenoidal pituitary tumor resection. During dura incision, brisk arterial bleeding was encountered from the right internal carotid artery. Immediate packing was performed, and hemostasis was achieved. Three days after the vessel injury, an angiography revealed a pseudoaneurysm (2.9 × 2.1 mm) at the cavernous segment of the right internal carotid artery, which showed enlargement on follow-up magnetic resonance imaging at six days postoperatively. Pipeline embolization was performed nine days after the vessel injury. Angiography performed one month after Pipeline embolization revealed significant stagnation but not complete occlusion of blood flow inside the pseudoaneurysm cavity. Dual antiplatelet therapy was replaced with single antiplatelet therapy. Follow-up angiograms three months after Pipeline embolization confirmed complete obliteration of the pseudoaneurysm and successful endoluminal reconstruction of the damaged vessel. Despite the possibility of short-term bleeding and the need for dual antiplatelet therapy administration for a certain period, the use of flow-diverting stents is a feasible vessel-sparing option in the management of intracranial internal carotid artery pseudoaneurysms resulting from transsphenoidal surgery injuries if intraoperative hemodynamic stability can be achieved with effective packing.

Flow diverters as a scaffold for treating direct carotid cavernous fistulas

Background

Direct 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.

Methods

We describe our experience treating patients with dCCFs in whom the PED was placed as the primary treatment modality.

Results

Five 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.

Conclusions

We 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.

Clinical classification and individualized design for the treatment of basicranial artery injuries

This study aims to explore the principles of clinical classification and individualized treatment of basicranial artery injuries based on its anatomical correlation.The data of 172 patients with various types of basicranial artery injuries were retrospectively analyzed. Among these patients, 128 patients were male and 44 patients were female, and the average age of these patients was 28.3 years old. All patients underwent computed tomography, some patients underwent computed tomography angiography or magnetic resonance angiography, and all the diagnoses were confirmed by digital subtraction angiography (DSA). According to anatomical correlation, the injuries were classified into 5 types: vascular wall injury (type I), intradural injury (type II), epidural injury (type III), sinus injury (type IV), and skull base bone injury (type V). Individualized treatment was adopted based on the different types and characteristics of injuries.The percentages of basicranial artery injuries were as follows: type I, 4.6%; type II, 5.8%; type III, 3.5%; type IV, 77.9%; and type V, 8.1%. All 172 patients underwent DSA to demonstrate the classification. The lesion elimination rate revealed by DSA was 99.4% immediately after the operation, 98.3% at 1 week after the operation, and 98.8% at 3 months after the operation. The follow-up after 6 months revealed that the percentage of patients in whom clinical symptoms or signs completely disappeared was 97.7%, the percentage of patients with limited eye movement or visual impairment was 1.2%, and the percentage of patients with mild limb dysfunction was 0.6%.Basicranial artery injuries can be classified into 5 types. Individualized design of embolization therapy based on different characteristics might be applicable for basicranial artery injuries treatment.

Treatment of direct carotid-cavernous fistulas with flow diversion - does it work?

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.

Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms

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.

Surpass Streamline Flow-Diverter Embolization Device for Treatment of Iatrogenic and Traumatic Internal Carotid Artery Injuries

Iatrogenic and traumatic cerebral internal carotid artery injuries are uncommon but potentially lethal complications. Direct surgical repair of ICA injuries may be difficult in an acute setting. However, endovascular treatment with a flow-diverter embolization device is a feasible alternative technique that we experienced. In this clinical report, we describe demographic data, radiographic images, lesion characteristics, endovascular procedure notes, postprocedural hospital course, and follow-up digital subtraction angiography of 5 patients. At least 6-month follow-up was available in all patients without occurrence of rebleeding and other complications.

Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms

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.

Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report

Background

Currently, transsphenoidal surgery (TSS) is the preferred method for surgical treatment of intrasellar pituitary adenomas. However, it carries some risk of intraoperative arterial injuries, which is mainly attributed to direct iatrogenic rupture of the internal carotid artery (ICA). There is anecdotal evidence suggesting that intracranial aneurysms are coincidentally found significantly more frequently in the setting of pituitary adenomas than when the incidence is compared to other intracranial neoplasms. The exact cause of this discrepancy remains unclear, but it certainly raises concerns about the potential existence of an ICA aneurysm, which might be encountered during TSS and in some cases may cause hemorrhagic complications.

Case Description

We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm which was embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor was associated with enlargement of the observed aneurysm, warranting endovascular intervention.

Conclusions

This case report is an illustration for physicians to be conscientious about the potential danger posed by the coexistence of an intratumoral aneurysm in the setting of a pituitary adenoma. Special attention should be given to recognition of an intrinsic flow void signal on the presurgical imaging of the tumor, and if observed, magnetic resonance angiography (MRA) should be performed for preoperative planning. If MRA is not performed routinely, detailed review of high-resolution magnetic resonance imaging is recommended to detect any flow artifacts suggestive of an aneurysm.

Staged curative treatment of a complex direct carotid-cavernous fistula with a large arterial defect and an 'oversized' internal carotid artery

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.

Direct carotid-cavernous fistula: A complication of, and treatment with, flow diversion

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.

Unilateral Direct Carotid Cavernous Fistula Causing Bilateral Ocular Manifestation

Unilateral carotid cavernous fistula presents with ipsilateral ocular findings. Bilateral presentation is only seen in bilateral fistulas, usually associated with indirect (dural) carotid cavernous fistulas. Direct carotid cavernous fistulas are an abnormal communication between the internal carotid artery and the cavernous sinus. They typically begin with a traumatic disruption in the artery wall into the cavernous sinus, presenting with a classic triad of unilateral pulsatile exophthalmos, cranial bruit and episcleral venous engorgement. We report the case of a 38-year-old male with traumatic right carotid cavernous sinus fistula and bilateral ocular presentation successfully treated by interventional neuroradiology.