Traumatic aneurysm of the supraclinoid internal carotid artery and an associated carotid—cavernous fistula: vascular reconstruction performed using intravascular implantation of stents and coils

Traumatic Supraclinoid Internal Carotid Artery Pseudoaneurysm associated with Carotid-Cavernous Fistula and Contralateral Anterior Cerebral Artery Pseudoaneurysm Treated by Surgical Trapping with High-Flow Bypass and A3-A3 Bypass: A Case Report and Literature Review

Traumatic pseudoaneurysms of the supraclinoid internal carotid artery (ICA) are uncommon, particularly associated with carotid-cavernous fistulas (CCF) or multiple traumatic aneurysms. This report describes a patient with a ruptured left ICA dissecting pseudoaneurysm that caused a direct CCF and a right anterior cerebral artery (ACA) pseudoaneurysm. To eliminate the aneurysm and fistula, we followed the universal bypass strategy by performing an ICA trapping with high-flow bypass, followed by an ACA trapping with A3-A3 side-to-side bypass. Herein, we report the first successful surgical trapping and revascularization of supraclinoid ICA pseudoaneurysm associated with a direct carotid-cavernous fistula.

Transradial Comaneci-assisted coiling of a direct carotid-cavernous fistula

Direct carotid-cavernous fistula is a communication between the internal carotid artery and the cavernous sinus, most of the times established following trauma or rupture of a cavernous aneurysm. The most commonly used treatments (coils, detachable latex balloons, stents, or liquid agents) carry ischemic or hemorrhagic risks, related to hemodynamic diversion of cerebral blood flow or permanent dual antiplatelet therapy. We report a case of coiling of a carotid-cavernous fistula assisted by the Comaneci, a temporary adjustable bridging mesh (Rapid Medical, Israel), to avoid transarterial or -venous migration. In our experience, Comaneci-assisted coiling represents a feasible solution to maintain patency of the distal vessels during coiling and avoid dual antiplatelet medications, even using a transradial approach.

Endovascular coil occlusion of traumatic intradural aneurysm with presentation as carotid cavernous fistula

Carotid cavernous fistulae (CCF) are abnormal communication between cavernous segment of the internal carotid artery and cavernous sinus. These entities are usually encountered in 0.2-0.8% of patients with traumatic skull base fractures. Traumatic cerebral aneurysms are rare and account for less than 1% of intracranial aneurysms. CCF due to ruptured intradural traumatic aneurysm is very rare and difficult to treat by surgical methods. We present one such case of a 40-year-old man with post-traumatic CCF due to a ruptured intradural aneurysm successfully treated with endovascular embolization.

Coils and Onyx Embolization of Traumatic Carotid-Cavernous Fistula Caused by an Intradural Internal Carotid Artery Pseudoaneurysm

A rare case of traumatic carotid-cavernous fistula caused by an intradural internal carotid artery pseudoaneurysm arising from the intradural internal carotid artery is described. The presentation was similar to that of carotid-cavernous fistulae, with ocular pain, chemosis and proptosis being the common symptoms. The patient was successfully treated by transarterial coil and Onyx-34 embolization. A 40-year-old man presented with severe injury, including multiple fractures of ribs, clavicle scapula and blind left eye. He gradually recovered and was discharged after intensive treatment in a local hospital. But about 70 days after discharge, his left eye became gradually chemotic and he felt a pulsatile bruit in his left ear. A CT scan and DSA confirmed a large intradural pseudoaneurysm and the associated carotid-cavernous fistula. Angiography revealed a fistula between the intradural aneurysm and the cavernous sinus. The origin of the aneurysm was above the posterior communicating artery. The aneurysm was successfully obliterated with detachable coils and Onyx-34 with the protection of a Hyperglide balloon. Subsequent studies demonstrated no flow through the fistula and good opacification of the ipsilateral internal cerebral artery system. Intradural pseudoaneurysm associated with carotid-cavernous fistula is a rare sequel of trauma. It may be treated successfully with the use of transarterial coil and Onyx embolization.

Embolization using endovascular technique in acute and chronic stages of traumatic ophthalmic artery aneurysm - case report -

A 44-year-old man presented with traumatic aneurysm of the left ophthalmic artery. The first coil embolization intervention achieved relatively tight packing of the aneurysm and the parent artery. After 5 months, a second embolization procedure was required because of recurrence of the aneurysm with transition of the intraaneurysmal coil formation. No recurrence occurred after the second embolization. We thought that the first embolization might have prevented catastrophic rupture, whereas the second embolization resulted in complete obliteration of the aneurysm. No entity of the aneurysmal wall formation of the current traumatic aneurysm in the acute stage may have resulted in the recanalization of the aneurysm followed by the second intervention. The stability of the wall in the chronic stage may correlate with the complete obliteration.

Successful Transarterial Guglielmi Detachable Coil Embolization of Post-Traumatic Fistula between a Posterior Communicating Artery Aneurysm and the Cavernous Sinus. A Case Report

SUMMARY

We describe a case of a post-traumatic posterior communicating artery (PCoA) aneurysm-cavernous sinus fistula, which is an extremely rare complication of craniocerebral trauma, successfully treated with endosaccular coil embolization via transarterial route. Endosaccular embolization with Guglielmi detachable coils via transarterial route appears to be a feasible, effective and minimally invasive option for the treatment of post-traumatic fistula between the PCoA aneurysm with a small ostia and the cavernous sinus in the subacute phase.

Wartime Traumatic Aneurysms

OBJECTIVE

Operation Iraqi Freedom has resulted in a significant number of closed and penetrating head injuries, and a consequence of both has been the accompanying neurovascular injuries. Here we review the largest reported population of patients with traumatic neurovascular disease and offer our experience with both endovascular and surgical management.

METHODS

A retrospective analysis of all military casualties returning to the Walter Reed Army Medical Center and the National Naval Medical Center, Bethesda, Maryland, from April 2003 until April 2008 was performed. All patients undergoing diagnostic cerebral angiography during their inpatient stay were included in the study.

RESULTS

A total of 513 war trauma-related consults were performed from April 2003 to April 2008, resulting in the evaluation of 408 patients with closed and penetrating head injuries. In this population, 279 angiographic studies were performed in 187 patients (25 closed craniocervical injuries, 162 penetrating craniocervical injuries), resulting in the detection of 64 vascular injuries in 48 patients (26.2% of those studied, 34% prevalence). Vascular injuries were characterized by traumatic intracranial aneurysms (TICAs) (n = 31), traumatic extracalvarial aneurysms (TECAs) (n = 19), arterial dissections (n = 11), and arteriovenous fistulae (n = 3). The average TICA size on admission was 4.1 mm, with an observed increase in aneurysm size in 11 cases. In the TICA/TECA group, 24 aneurysms in 23 patients were treated endovascularly with either coiling or stent-assisted coiling, resulting in preservation of the parent artery in 12 of 24 vessels (50%). The injuries in 3 patients in this group progressed despite endovascular treatment and required definitive clip exclusion. Thirteen additional aneurysms in 8 patients were treated surgically, resulting in parent artery preservation in 4 cases (30.8%). Eleven of the 13 remaining TICAs/TECAs resolved spontaneously without treatment. A total of 6 aneurysm ruptures (average size, 8.25 mm) occurred, resulting in 3 deaths. Four of 6 ruptures occurred in TICAs in which the interval size increase was noted angiographically.

CONCLUSION

The management of traumatic vascular injury has evolved with technological advancement and the willingness of the neurosurgeon to intervene. Although open surgical intervention remains a viable solution, endovascular options are available and safe and can effectively temporize a patient while acute sequelae of serious head injury resolve.

Traumatic aneurysm of the supraclinoid internal carotid artery-case report-

A 23-year-old male was admitted after a motor vehicle accident with acute epidural hematoma, diffuse subarachnoid hemorrhage (SAH) in the basal cistern, and fractures at the anterior cranial base. Angiography revealed an aneurysm of the right supraclinoid internal carotid artery (ICA). His consciousness suddenly worsened on the 23rd day. Expansion of the SAH in the basal cistern and two hump aneurysms were detected. He underwent endovascular embolization of these aneurysms and the right ICA with Guglielmi detachable coil. Traumatic aneurysms are difficult to diagnose in the early period after injury and are associated with a high mortality. Endovascular treatments for traumatic aneurysms have lower mortality rate, and can be performed under local anesthesia.

Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels

BACKGROUND

Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times.

METHODS

A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma.

RESULTS

In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%.

CONCLUSION

The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.

Endovascular stenting for the treatment of traumatic internal carotid injuries: expanding experience

BACKGROUND

The role of endovascular techniques in the treatment of traumatic vascular injuries, including injury to the internal carotid artery, continues to evolve. Despite growing experience with the usage of these techniques in the setting of artherosclerotic disease, published results in traumatic carotid injuries remain sporadic and confined to case reports and case series.

METHODS

We conducted a review of the medical literature from 1990 to the present date using the Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of carotid injuries. Thirty-one published reports were analyzed to abstract data regarding mechanism, location, and type of injury; use and type of anticoagulation used in conjunction with stenting; type and timing of radiographic and clinical follow-up; and radiographic and clinical outcomes.

RESULTS

The use of endovascular stenting for the treatment of internal carotid injuries was reported for only 113 patients from 1994 to the present date. Stenting was most commonly used after a blunt mechanism of injury (77.0%). The injury types treated by stenting included pseudoaneurysm (60.2%), arteriovenous fistula (16.8%), dissection (14.2%), partial transection (4.4%), occlusion (2.7%), intimal flap (0.9%), and aneurysm (0.9%). Initial endovascular stent placement was successful in 76.1% of patients. Radiographic and clinical follow-up periods ranging from 2 weeks to 2 years revealed a follow-up patency of 79.6%. No stent-related mortalities were reported. New neurologic deficits after stent placement occurred in 3.5%.

CONCLUSION

Endovascular treatment of traumatic internal carotid artery injury continues to evolve. Early results are encouraging, but experience with this modality and data on late follow-up are still very limited. A large prospective randomized trial is warranted to further define the role of this treatment modality in the setting of trauma.

The potential of flow modification in the treatment of intracranial aneurysms

Abstract:

BACKGROUND AND PURPOSE

To summarize the theoretical background and existing technical achievements of flow modification techniques in the treatment of intracranial aneurysms. The evolution of the concept of flow modification for aneurysm treatment is overviewed within the published literature on application of stents for aneurysms. The newest achievements using dedicated flow modifying devices is discussed. Reconstruction of laminar flow within intracranial arteries harboring aneurysms is feasible. Reorientation of flow using dedicated flow modifying devices is a highly effective technique in the treatment of large, broad neck, otherwise untreatable aneurysms.

Endovascular Treatment of a High-Flow Direct Traumatic Carotid Cavernous Fistula with a Two Year Follow-up

SUMMARY

Endovascular treatment of high-flow direct traumatic carotid cavernous fistula (CCF) carries many difficulties. One of them is that carotid dissection may be associated with pseudo- aneurysm formation even when the CCF can be successfully embolized by detachable balloons. This article details a unique technique of treating pseudo-aneurysm by obstructing the lumen with preservation of the parent artery. The case presented here involves a 50-yearold man with a history of severe trauma. The angiography revealed that his bilateral highflow carotid cavernous fistula was successfully embolized by detachable balloons and control digital subtraction angiography at the end of the procedure demonstrated the fistula closed and the internal carotid artery preserved. But two months later, a pseudo-aneurysm formed in the right internal carotid artery. Under endovascular treatment along with other techniques including coils, stent-assisted and covered stent, the pseudo-aneurysm was excluded with preserved ICA. Two years later, the fistula and pseudo-aneurysm both disappeared quietly without patent foreign body reaction in the parent arterial wall.

Treatment of carotid cavernous fistulas using covered stents: midterm results in seven patients

BACKGROUND AND PURPOSE

Carotid cavernous fistulas (CCF) can be effectively treated by using different therapeutic alternatives such as detachable balloons and detachable coils, alone or in combination with N-butyl-2-cyanoacrylate (n-BCA) or Onyx. Stents have also been used in an attempt to improve preservation of the parent artery while still occluding the fistula. We present our experience using balloon-expandable covered stents to treat CCF, focusing on arterial wall reconstruction. To our knowledge, this is the first series with midterm follow-up between 3 months and 3.5 years.

MATERIALS AND METHODS

From the 46 CCF treated at our institution between November 1998 and September 2006, a total of 7 posttraumatic direct CCF were treated using polytetrafluoroethylene (PTFE)-covered stents between April 2003 and September 2006. Five were treated with covered stents alone. One patient with transection of the internal carotid artery (ICA) first underwent bare stent placement to provide support for the covered stent. One patient had to be treated with coils and n-BCA.

RESULTS

Control angiograms obtained in the 7 patients demonstrated occlusion of the fistula and preservation of the ICA in all cases. There was no mortality and no immediate postprocedural morbidity. There was 1 case of morbidity identified at 1-month follow-up with asymptomatic occlusion of the ICA; the other 6 patients had angiographic follow-up between 3 and 42 months (mean, 18.4 months), with persistent occlusion of the fistulas, patent stent grafts, and no significant intimal hyperplasia.

CONCLUSIONS

PTFE-covered stents are evolving as a promising intracranial therapeutic alternative to treat CCF and preserve the parent artery by reconstructing the arterial wall. They should be considered in patients in whom fistulas cannot be successfully occluded with detachable balloons or detachable coils. More investigation is required to further develop their specifications and indications.

Traumatic cerebral aneurysm associated with a contralateral traumatic carotid cavernous fistula. A case report

SUMMARY

This report documents the management of a traumatic carotid aneurysm (TCA) with a traumatic carotid-cavernous fistula (T-CCF) of the contralateral internal carotid artery (ICA) following a closed head injury. A 38-year-old man presented with severe traumatic subarachnoid hemorrhage and pneumocephalus due to a severe head injury. Four months after the accident, the patient presented with clinical symptoms of exophthalmos and retroorbital bruit. Cerebral angiography showed a TCA of the IC-PC region, which coexisted with a contralateral T-CCF. Both lesions were successfully managed with an endovascular treatment using coils to isolate a fistula from the ICA, and direct surgical trapping of the intracranial ICA to eliminate a TCA. Post-operative angiography revealed a good cross-flow through the anterior communicating artery from the contralateral ICA, which was completely obliterated by the T-CCF. No additional surgical or endovascular procedure for traumatic vascular injuries was required. The patient remained asymptomatic during the clinical follow-up period of 24 months. The goal of traumatic carotid injuries is the selective elimination of the vascular pathologic injury with asymptomatic state, using direct surgery and/or an endovascular treatment.

Covered stent-graft treatment of traumatic internal carotid artery pseudoaneurysms: a review

OBJECTIVE

To review the literature concerning the management with placement of covered stent-grafts of traumatic pseudoaneurysms of the extracranial internal carotid artery (ICA) resulting from penetrating craniocervical injuries or skull base fractures.

METHOD

We have reviewed, from the Medline database, all the published cases in the English literature since 1990 and we have added a new case.

RESULTS

We identified 20 patients with traumatic extracranial ICA pseudoaneurysms due to penetrating craniocervical injuries or skull base fractures who had been treated with covered stent-graft implantation. Many discrepancies have been ascertained regarding the anticoagulation therapy. In 3 patients the ICA was totally occluded in the follow-up period, giving an overall occlusion rate 15%. No serious complication was reported as a result of the endovascular procedure.

CONCLUSION

Preliminary results suggest that placement of stent-grafts is a safe and effective method of treating ICA traumatic pseudoaneurysms resulting from penetrating craniocervical injuries or skull base fractures. The immediate results are satisfactory when the procedure takes place with appropriate anticoagulation therapy. The periprocedural morbidity and mortality and the early patency are also acceptable. A surveillance program with appropriate interventions to manage restenosis may improve the long-term patency.

Return of vision after transarterial coiling of a carotid cavernous sinus fistula: case report

BACKGROUND

Carotid cavernous sinus fistulae are abnormal communications between the carotid circulation and cavernous sinus that may arise spontaneously or develop after craniocerebral trauma. They may present with a constellation of signs and symptoms characteristic of raised cavernous sinus pressure, including orbital or retro-orbital pain, pulsatile proptosis, chemosis, ocular or cranial bruit, deterioration of visual acuity, or ophthalmoplegia. Visual loss is likely the result of multiple insults to the visual system, including reversal of venous drainage from the fistula, arterial flow into the superior ophthalmic vein, increased intraocular venous pressure, venous stasis retinopathy, and eventually ischemic optic neuropathy [Brodsky MC, Hoyt WF, Halbach VV, et al. Recovery from total monocular blindness after balloon embolization of carotid-cavernous fistula. Am J Ophthalmol 1987;104:86-87; Sanders MD, Hoyt WF. Hypoxic ocular sequelae of carotid-cavernous fistulae: study of the causes of visual failure before and after neurosurgical treatment in a series of 25 cases. Br J Ophthalmol 1969;53:82-97].

CASE DESCRIPTION

With few exceptions, the literature is replete with evidence of persistent blindness despite successful treatment of the CCF [Albuquerque FC, Heinz GW, McDougall CG. Reversal of blindness after transvenous embolization of a carotid-cavernous fistula: case report. Neurosurgery 2003;52:233-237; Brodsky MC, Hoyt WF, Halbach VV, et al. Recovery from total monocular blindness after balloon embolization of carotid-cavernous fistula. Am J Ophthalmol 1987;104:86-87; Weinstein JM, Rufenacht DA, Partington CR, et al. Delayed visual loss due to trauma of the internal carotid artery. Arch Neurol. 1991;48:490-497]. Here, we report a patient who experienced recovery of vision after endovascular obliteration of the offending CCF.

DISCUSSION

To our knowledge, this is the second reported case of recovery of visual function in a patient presenting with loss of light perception after treatment of a direct CCF.

Endovascular treatment of intracranial aneurysms with parent vessel reconstruction using balloon and self expandable stents

BACKGROUND AND PURPOSE

To assess the feasibility and results of parent vessel stent reconstruction with balloon expandable and self-expandable stents in the treatment of intracranial aneurysms.

METHODS

In a total of 18 aneurysms balloon expandable (group A) and self expandable (group B) stents were used in 9 cases each. Stent implantation alone was used in 3 cases, and additional coil packing in the other 15.

RESULTS

Stents were successfully deployed in 8 out of 9 in group A and in 9 out of 9 cases in group B. Nearly complete occlusion was achieved in all but one case. At 3 or 6 months stable occlusion was found in 4 group A and 2 group B patients, progressive thrombosis in 3 cases in both groups, and recanalisation in 1 case in group B. Late follow up at 1-4 years demonstrated one progressive thrombosis one recanalisation and 1 stable occlusion in 3 group A, and 2 stable occlusions in 2 group B. patients. Complications included one aneurysm perforation in group A, one in-stent thrombosis and a distal arterial perforation in group B and one groin hematoma in both groups.

CONCLUSION

Stent reconstruction of intracranial arteries harbouring aneurysms is feasible and may result in aneurysm thrombosis without coil packing in some cases. Self expanding stents seem to provide a higher rate of success. Aggressive antiplatelet treatment increases the risk of hemorrhagic complications.

Therapeutic Endovascular Treatments for Traumatic Carotid Artery Injuries

OBJECTIVE

The diagnosis and management of traumatic carotid vessel injuries continue to be controversial, with direct surgical repair with parent artery preservation still presenting difficulties. The purpose of this report is to review the endovascular therapy of patients with traumatic carotid vessel injuries for preservation of the parent artery, and to determine the safety and efficacy of endovascular therapy.

METHODS

Ten patients with traumatic carotid lesions were treated using therapeutic endovascular methods. Endovascular therapy was accomplished by implanting balloons, porous or polytetrafluoroethylene-covered stents, and/or embolic materials including coils or glue.

RESULTS

All fistulas and pseudoaneurysms were successfully embolized with no periprocedural complications including vessel disruption/rupture, distal embolization, or new neurologic deficits. The parent arteries of all patients except one were preserved. The reason for the parent artery sacrifice was a thrombus formation due to coil migration into the parent artery. No additional surgical procedures for vascular lesions were required. There were no delayed neurologic or vascular complications, and no lesions recurred during the follow-up periods (mean 20.3 months).

CONCLUSION

The goal of endovascular therapy is the selective elimination of the vascular pathology with the normal patency of the cerebral arteries. The authors' experience demonstrates that endovascular therapy using stents, balloons, and coils is both feasible and safe for treatment of traumatic carotid injuries. Of these endovascular methods, the stent can be used to exclude the aneurysm or fistula from the circulation and preserve the parent artery in selective cases. Long-term follow-up review of these repairs will be necessary to provide a full evaluation of the safety and efficacy of these devices.

Therapeutic advances in interventional neurology

Rapid advances in the field of interventional neurology and the development of minimally invasive techniques have resulted in a great expansion of potential therapeutic applications. We discuss therapeutic interventional neurology as applied in clinical practice in one of the two possible ways: 1) embolization leading to occlusion of blood vessels; and 2) revascularization leading to reopening of blood vessels. These procedures can be applied to a broad range of cerebrovascular diseases. In the first section of this review, we will explore the evolution of these interventions to occlude aneurysms, arteriovenous malformations, neurovascular tumors, and injuries. In the second section, revascularization in acute ischemic stroke, stenosis, and dural venous thrombosis will be discussed.