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Howard BM, Barrow DL. Carotid Cavernous Fistula. Neurosurg Clin N Am 2024; 35:319-329. [PMID: 38782525 DOI: 10.1016/j.nec.2024.02.004] [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: 05/25/2024]
Abstract
Carotid cavernous fistulae (CCFs) are arteriovenous shunts involving the cavernous sinus. CCFs are defined as direct or indirect. Direct CCFs are treated by deconstructive or reconstructive techniques depending on whether the affected internal carotid artery is required to perfuse the ipsilateral cerebral hemisphere, as determined by a balloon test occlusion. Indirect CCFs, or dural fistulae of the cavernous sinus wall, are most often treated with transvenous embolization. Stereotactic radiosurgery is reserved for cases of indirect CCFs that are not completely obliterated by embolization. Overall, cure rates are high with relatively low complication rates.
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Affiliation(s)
- Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, 1365 Clifton Road Northeast, Suite. B6200, Atlanta, GE 30322, USA; Department of Radiology and Imaging Sciences, Division of Interventional Neuroradiology, Emory University School of Medicine, 1364 Clifton Road NE, AG26, Atlanta, GE 30322, USA.
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University School of Medicine, 1365 Clifton Road Northeast, Suite. B6200, Atlanta, GE 30322, USA
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2
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Vranic JE, Regenhardt RW, Awad A, Doron O, Rabinov J. Endovascular and medical management strategies for carotid-cavernous fistulas: A safety and efficacy analysis. Interv Neuroradiol 2024:15910199241261761. [PMID: 38881351 DOI: 10.1177/15910199241261761] [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: 06/18/2024] Open
Abstract
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.
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Affiliation(s)
- Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amine Awad
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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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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Tatebayashi K, Shirakawa M, Abe S, Fujita M, Yoshimura S. Vascular Ehlers-Danlos syndrome with a Novel missense COL3A1 gene mutation present with bilateral spontaneous carotid-cavernous fistula: a case report. Acta Neurochir (Wien) 2023; 165:3799-3804. [PMID: 37917379 DOI: 10.1007/s00701-023-05859-1] [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: 09/14/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
This report describes a unique case of vascular Ehlers-Danlos syndrome (vEDS) characterized by multiple spontaneous direct carotid-cavernous sinus fistulas (CCF). The patient initially presented with ocular symptoms and was effectively treated with transarterial coil embolization. Five years later, the patient developed recurrent contralateral CCF that required complex endovascular techniques. Genetic testing identified a novel mutation in the COL3A1 gene, confirming the diagnosis of vEDS. This case report provides a near-term perspective on the identification of structural abnormalities in the COL3A1 protein to ensure the safety of endovascular therapy for patients with vEDS.
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Affiliation(s)
- Kotaro Tatebayashi
- Department of Neurosurgery, Hyogo Medical University, 1-1 Mukogawacho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, 1-1 Mukogawacho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Soichiro Abe
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Mitsugu Fujita
- Center for Medical Education and Clinical Training, Kindai University Faculty of Medicine, Osaka, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, 1-1 Mukogawacho, Nishinomiya, Hyogo, 663-8501, Japan.
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Padmanaban V, Yee PP, Koduri S, Zaidat B, Daou BJ, Chaudhary N, Gemmete JJ, Thompson BG, Kazmierczak CD, Cockroft KM, Pandey AS, Wilkinson DA. Neuroendovascular Procedures in Patients with Ehlers-Danlos Type IV: Multicenter Case Series and Systematic Review. World Neurosurg 2023; 170:e529-e541. [PMID: 36402305 DOI: 10.1016/j.wneu.2022.11.067] [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: 08/18/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ehlers-Danlos type IV or vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited disorder characterized by profound vascular fragility resulting from defective production of type III procollagen. Cerebrovascular diseases including spontaneous dissections, cerebral aneurysms, and cavernous carotid fistulae are common. Endovascular therapies in this patient population are known to be higher risk, although many studies (before 2000) involved older techniques and equipment. The purpose of this study is to investigate the safety and efficacy of modern neuroendovascular techniques in the treatment of cerebrovascular diseases in patients with vEDS. METHODS We combined a multi-institutional retrospective case series at 3 quaternary-care centers with a systematic literature review of individual case reports and case series spanning 2000-2021 to evaluate the safety and efficacy of neuroendovascular procedure in patients with vEDS with cerebrovascular diseases. RESULTS Fifty-nine patients who underwent 66 neuroendovascular procedures were evaluated. Most of the patients had direct cavernous carotid fistulas (DCCF). Neuroendovascular procedures had a 94% success rate, with a complication rate of 30% and a mortality of 7.5%. CONCLUSIONS Neuroendovascular procedures can be performed with a high rate of success in the treatment of cerebrovascular diseases in patients with vEDS, although special care is required because complication rates and mortality are high. Access site and procedure-related vascular injuries remain a significant hurdle in treating vEDS with cerebrovascular diseases, even with modern techniques.
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Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Patricia P Yee
- Medical Scientist Training Program, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Bashar Zaidat
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Badih J Daou
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Chris D Kazmierczak
- Department of Radiology, Oakland University-William Beaumont School of Medicine, Auburn Hills, Michigan, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
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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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7
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Al-Ageely TA, Ismail M, Mohammed SA, Al-Delfi AH, Alshedidi MS, Al-Jaberi MB, Almufadhal MH, Abdulateef AA, Aljuboori Z, Al-Jehani H, Hoz SS. Failure of tandem flow diversion for intracranial aneurysms: Literature review and illustrative case. Surg Neurol Int 2022; 13:518. [DOI: 10.25259/sni_944_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background:
Flow diverters are becoming one of the main endovascular procedures used to treat aneurysms. Flow diverter devices (FDDs) have multiple types approved for endovascular procedure use. Although their indications are not well described, they are usually used for large or giant, wide-necked, and recurrent aneurysms. Multiple FDDs can be deployed to treat giant aneurysms to ensure and accelerate aneurysm occlusion and mitigate complications. We report a case of endovascular treatment of an intracranial aneurysm using three silk FDDs complicated by a delayed migration of the stents along the parent artery, along with a literature review of the related cases.
Methods:
We conducted a PubMed Medline database search by the following combined formula of subjects headings: ((((((intracranial aneurysm[MeSH Terms]) AND (endovascular procedure[MeSH Terms])) OR (endovascular technique[MeSH Terms])) AND (endovascular[Title/Abstract]) AND (Flow diverter[Title/ Abstract])) OR (flow diversion[Title/Abstract])) OR (Pipeline[Title/Abstract])) AND (Multiple[Title/Abstract]).
Results:
The result was eight cases of endovascular treatment of intracranial aneurysms with multiple FDD. The male-to-female ratio in these cases was 5:3, and there is a wide age range from 22 months to 69 years old. The cases differed in the type and number of FDDs used, yet, they all had similar results with aneurysm occlusion and recovery of the patient with no observed complications.
Conclusion:
Tandem flow diverter deployment has technical challenges and complications such as complete obstruction can occur. Planning and learning from experience with those new technologies are the typical way to overcome such complications in the future.
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Affiliation(s)
- Teeba A. Al-Ageely
- Department of Neurosurgery, University of Baghdad, College of Medicine, Al Risafa, Baghdad, Iraq,
| | - Mustafa Ismail
- Department of Neurosurgery, University of Baghdad, College of Medicine, Al Risafa, Baghdad, Iraq,
| | - Sara A. Mohammed
- Department of Neurosurgery, University of Baghdad, College of Medicine, Al Risafa, Baghdad, Iraq,
| | - Ali H. Al-Delfi
- Department of Neurosurgery, University of Alameed, College of Medicine, Karbala, Iraq,
| | - Muhammed S. Alshedidi
- Department of Neurosurgery, University of Alameed, College of Medicine, Karbala, Iraq,
| | | | - Muntadher H. Almufadhal
- Department of Neurosurgery, University of Baghdad, College of Medicine, Al Risafa, Baghdad, Iraq,
| | | | - Zaid Aljuboori
- Department of Neurosurgery, University of Wisconsin-Madison, Wisconsin, United States,
| | - Hosam Al-Jehani
- Department of Neurosurgery, Imam Abdulrahman Alfaisal University, Dammam, Saudi Arabia,
| | - Samer S. Hoz
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, United States
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