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de Liyis BG, Surya SC, Oden GF, Kosalya Arini AAI, Tini K, Niryana IW, Widyadharma IPE, Mahadewa TGB. Transarterial embolization in non-cavernous and cavernous sinus dural arteriovenous fistulas: A systematic review and meta-analysis of proportions. Clin Neurol Neurosurg 2024; 245:108478. [PMID: 39116793 DOI: 10.1016/j.clineuro.2024.108478] [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: 06/19/2024] [Revised: 07/14/2024] [Accepted: 07/30/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Transarterial embolization (TAE) is pivotal in managing non-cavernous and cavernous sinus dural arteriovenous fistulas (CSDAVFs). METHODS Systematic searches were conducted across ScienceDirect, Medline, and Cochrane databases for longitudinal studies on TAE outcomes in non-CSDAVFs and CSDAVFs. Post-procedural outcomes, including complete, incomplete, and failed AVFs obliteration, and end-study outcomes were analyzed. RESULTS Our meta-analysis involved 27 studies with 643 patients and 736 fistulas. Symptoms in both groups included tinnitus (29.74 %), ocular/visual symptoms (29.12 %), hemorrhage (19.42 %), and headache (19.11 %). Feeding arteries mainly originated from the meningeal arteries (49.16 %). In non-CSDAVFs cases, fistula locations were within sinus complexes (69.23 %) and specific dural areas (28.31 %). Complete AVFs obliteration was 81 % (95 %CI: 70 % - 90 %), slightly higher in non-CSDAVFs (82 %, 95 % CI: 69 % - 92 %) than CSDAVFs (79 %, 95 %CI: 58 % - 95 %). Incomplete obliteration occurred in 14 % (95 %CI: 5 % - 39 %), with rates of 11 % (95 %CI: 2 % - 26 %) in non-CSDAVFs and 19 % (95 % CI: 5 % - 39 %) in CSDAVFs. Failed obliteration was rare (1 %, 95 %CI: 0 % - 3 %), with similar rates in both groups. At end-study follow-up, resolution of AVFs was achieved in 97 % of cases (95 %CI: 92 % - 100 %). However, complications occurred in 17 % of cases (95 %CI: 10 % - 25 %), with a higher incidence in CSDAVFs (22 %, 95 %CI: 9 % - 37 %) compared to non-CSDAVFs (13 %, 95 %CI: 6 % - 23 %). CONCLUSIONS TAE with embolic agents demonstrates favorable outcomes in non-CSDAVFs and CSDAVFs, with high rates of AVFs obliteration and resolution. Complications, particularly in CSDAVFs, warrant careful consideration in treatment decisions.
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Affiliation(s)
| | | | | | | | - Kumara Tini
- Department of Neurology, Faculty of Medicine, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Indonesia
| | - I Wayan Niryana
- Department of Neurosurgery, Faculty of Medicine, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Indonesia
| | - I Putu Eka Widyadharma
- Department of Neurology, Faculty of Medicine, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Indonesia
| | - Tjokorda Gde Bagus Mahadewa
- Department of Neurosurgery, Faculty of Medicine, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Indonesia
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Yuan J, Yang R, Zhang J, Liu H, Ye Z, Chao Q. Covered Stent Treatment for Direct Carotid-Cavernous Fistulas: A Meta-Analysis of Efficacy and Safety Outcomes. World Neurosurg 2024; 187:e302-e312. [PMID: 38663732 DOI: 10.1016/j.wneu.2024.04.077] [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: 09/02/2023] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND Direct carotid-cavernous fistulas (dCCFs) involve the abnormal shunting of blood between the internal carotid artery and the cavernous sinus. The use of covered stents (CSs) has been reported for the treatment of complex carotid artery lesions. However, the efficacy and safety of CS treatment for dCCFs remain controversial. Thus, we performed a systematic review and meta-analysis to evaluate these efficacy and safety endpoints. METHODS A systematic literature review was performed by comprehensively searching the Medline, Embase, and Web of Science databases to identify studies that were related to CS treatment for dCCFs. Then, a meta-analysis was conducted to pool the efficacy and safety outcomes from these studies based on perioperative and follow-up data. RESULTS Fourteen noncomparative studies enrolling 156 patients with 160 dCCFs met the inclusion criteria. When analyzing perioperative outcomes, the technical success rate was 98.5% [95% confidence interval (CI), 0.948; 1.000], and the immediate complete occlusion rate was 90.9% (95% CI, 0.862; 0.959). Vasospasm and dissection occurred in 32.2% (95% CI, 0.238; 0.463) and 0.1% (95% CI, 0.000; 0.012) of patients, respectively. The in-stent acute thrombus formation rate was 0.1% (95% CI, 0.000; 0.013). Postoperatively, the mortality rate was 0.1% (95% CI, 0.000; 0.013). Based on available follow-up data, the final complete occlusion and parent artery stenosis rates were 99.3% (95% CI, 0.959; 1.000) and 18.6% (95% CI, 0.125; 0.277), respectively. CONCLUSIONS CS placement can be used to safely and effectively treat dCCFs. These results provide a reference for future clinical trials.
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Affiliation(s)
- Jiang Yuan
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Rongwei Yang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jiatong Zhang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Hexu Liu
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ziming Ye
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Qin Chao
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
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Seraj FQM, Najafi S, Raaisi AA, Mirbolouk MH, Ebrahimnia F, Shamsi HP, Garivani Y, Zabihyan S, Mowla A, Baharvahdat H. Treatment of Traumatic Direct Carotid-Cavernous Fistula with a BeGraft-Covered Stent. Neurointervention 2024; 19:111-117. [PMID: 38808398 PMCID: PMC11222683 DOI: 10.5469/neuroint.2024.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/15/2024] [Accepted: 05/21/2024] [Indexed: 05/30/2024] Open
Abstract
The widely accepted option for treating traumatic direct carotid-cavernous fistula (dCCF) has been endovascular treatment using detachable balloons, coils, or embolic agents. Covered stent deployment has been applied by a few operators and has shown promising results. This is a retrospective study on patients with dCCF treated by an endovascular approach using BeGraft, a covered stent. In 4 cases, this device was successfully deployed without any complications. Immediate complete occlusion was achieved in 3 patients (75%) after deployment of the covered stents. One patient required transvenous coiling for occlusion of the remaining endoleak. Follow-up imaging demonstrated 100% fistula occlusion with complete internal carotid artery patency. No early or late complications occurred following treatment. In conclusion, the BeGraft-covered stent could be a promising safe and effective alternative option for the endovascular treatment of dCCF.
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Affiliation(s)
- Farid Qoorchi Moheb Seraj
- Department of Neurosurgical, Section of Neurovascular, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajjad Najafi
- Department of Neurosurgical, Section of Neurovascular, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Neurosurgery, Emam Hospital, Mazandaran University of Medical Sciences, School of Medicine, Sari, Iran
| | - Amira Al Raaisi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Mohammad Hossein Mirbolouk
- Department of Neurosurgery, Firouzgar Hospital, Iran University of Medical Sciences, School of Medicine, Tehran, Iran
| | - Feizollah Ebrahimnia
- Department of Neurosurgical, Section of Neurovascular, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hashem Pahlavan Shamsi
- Department of Neurosurgical, Section of Neurovascular, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Yousef Garivani
- Department of Neurosurgical, Section of Neurovascular, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samira Zabihyan
- Department of Neurosurgical, Section of Neurovascular, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Humain Baharvahdat
- Department of Neurosurgical, Section of Neurovascular, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
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Koh DH, Choi HC, Shin HS, Baek HJ, Koh EH, Park MJ, Choi DS. Endovascular Treatment of Traumatic Vascular Injuries in the Head and Neck Region. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:269. [PMID: 38399556 PMCID: PMC10890514 DOI: 10.3390/medicina60020269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Traumatic vascular injuries of the head and neck pose significant treatment challenges due to the complex anatomy, diverse clinical presentation, and mostly emergent nature. Endovascular treatment increasingly complements traditional surgical approaches. This study aimed to report our 10-year experience in treating traumatic vascular injuries of the head and neck with endovascular therapy and to determine the effectiveness of endovascular treatment. Materials and Methods: A retrospective analysis of 21 patients treated for head and neck vascular injuries between May 2011 and April 2021 was performed. Patients' medical histories, clinical presentations, imaging findings, treatment materials, and clinical outcomes were reviewed. Treatments included stenting, coil embolization, and other endovascular techniques focused on hemostasis and preservation of the parent vessel. Results: The most common injuries involved the internal maxillary artery branches (n = 11), followed by the common or internal carotid artery (n = 6), vertebral artery (n = 3), and others. Endovascular treatment achieved successful hemostasis in all but one case. In five of six carotid artery injuries and two of three vertebral artery injuries, we achieved successful hemostasis while preserving the parent vessel using covered and bare stents, respectively. Conclusions: Endovascular therapy might be a useful treatment modality for traumatic vascular injuries in the head and neck region, offering efficacy, safety, and a minimally invasive approach.
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Affiliation(s)
- Dong Hyun Koh
- Department of Medicine, Gyeongsang National University College of Medicine, 816-15 Jinju-daero, Jinju 52727, Republic of Korea; (D.H.K.); (H.J.B.); (E.H.K.)
- Department of Radiology, Gyeongsang National University Hospital, 79 Gangnam-ro, Jinju 52727, Republic of Korea; (H.C.C.); (H.S.S.)
| | - Ho Cheol Choi
- Department of Radiology, Gyeongsang National University Hospital, 79 Gangnam-ro, Jinju 52727, Republic of Korea; (H.C.C.); (H.S.S.)
| | - Hwa Seon Shin
- Department of Radiology, Gyeongsang National University Hospital, 79 Gangnam-ro, Jinju 52727, Republic of Korea; (H.C.C.); (H.S.S.)
| | - Hye Jin Baek
- Department of Medicine, Gyeongsang National University College of Medicine, 816-15 Jinju-daero, Jinju 52727, Republic of Korea; (D.H.K.); (H.J.B.); (E.H.K.)
- Department of Radiology, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon 51472, Republic of Korea
| | - Eun Ha Koh
- Department of Medicine, Gyeongsang National University College of Medicine, 816-15 Jinju-daero, Jinju 52727, Republic of Korea; (D.H.K.); (H.J.B.); (E.H.K.)
- Gyeongsang Institute of Medical Science, Gyeongsang National University College of Medicine, 816-15 Jinju-daero, Jinju 52727, Republic of Korea
| | - Mi Jung Park
- Department of Medicine, Gyeongsang National University College of Medicine, 816-15 Jinju-daero, Jinju 52727, Republic of Korea; (D.H.K.); (H.J.B.); (E.H.K.)
- Department of Radiology, Gyeongsang National University Hospital, 79 Gangnam-ro, Jinju 52727, Republic of Korea; (H.C.C.); (H.S.S.)
| | - Dae Seob Choi
- Department of Medicine, Gyeongsang National University College of Medicine, 816-15 Jinju-daero, Jinju 52727, Republic of Korea; (D.H.K.); (H.J.B.); (E.H.K.)
- Department of Radiology, Gyeongsang National University Hospital, 79 Gangnam-ro, Jinju 52727, Republic of Korea; (H.C.C.); (H.S.S.)
- Gyeongsang Institute of Medical Science, Gyeongsang National University College of Medicine, 816-15 Jinju-daero, Jinju 52727, Republic of Korea
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Hoffman H, Ashok Kumar A, Wood JS, Mikhailova T, Yoo JH, Wakeman MB, Masoud HE, Gould GC. Outcomes After Endovascular Treatment of Direct Carotid Cavernous Fistulas: Systematic Review and Meta-Analysis. World Neurosurg 2023; 170:e242-e255. [PMID: 36334712 DOI: 10.1016/j.wneu.2022.10.123] [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: 09/10/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Direct carotid cavernous fistulas (dCCF) involve pathologic shunting from the internal carotid artery into the cavernous sinus. We systematically reviewed the methods and outcomes of endovascular therapy for dCCF. METHODS PubMed, Scopus, and EMBASE were used to identify studies that reported outcomes for patients undergoing embolization of dCCF. Outcomes included rates of occlusion, complications, symptom improvement, and recurrence. Pooled rates for each outcome were obtained with random effects models. The influence of embolization method on outcomes was assessed with meta-regressions. RESULTS There were 16 studies comprising 270 patients. The mean age was 39.6 years, there were 36.3% females, and the mean follow-up was 19.7 months. Coils were the most common method of embolization (69.3%), followed by Onyx (31.1%), covered stent (22.2%), N-butyl cyanoacrylate (6.7%), and flow diversion (4.8%). The pooled overall occlusion rate was 92.1% (95% confidence interval [CI], 86.3-95.6; I2 = 29.2%). The pooled complication rate was 10.9% (95% CI, 7.3-16; I2 = 0%). Use of coils were associated with a slightly lower odds of overall complications (odds ratio, 0.98; 95% CI, 0.97-0.99) and cranial nerve palsy (odds ratio, 0.98; 95% CI, 0.97-0.99). The pooled fistula recurrence rate was 8.3% (95% CI, 4.3-15.4; I2 = 30.9%). CONCLUSIONS Endovascular therapy for dCCF is associated with high occlusion and low complication rates. Recurrence is not uncommon, highlighting the need for close follow-up.
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Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA.
| | - Apeksha Ashok Kumar
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Jacob S Wood
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Tatiana Mikhailova
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Jae Hyun Yoo
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Melia B Wakeman
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Hesham E Masoud
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Grahame C Gould
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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Awad A, Regenhardt RW, Dmytriw AA, Vranic JE, Marciano RD, Patel AB, Stapleton CJ. Flow diversion in direct carotid-cavernous fistula refractory to multiple coil embolizations: case report and review of the literature. J Stroke Cerebrovasc Dis 2022; 31:106840. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/20/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022] Open
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Wang T, Richard SA, Zhang C, Xie X, Wang C. The Appearance of Middle Meningeal Artery Fistulae After Willis Covered Stent for Traumatic Carotid-cavernous Fistulae: Two Case Reports. Curr Med Imaging 2021; 17:1025-1030. [PMID: 33459242 DOI: 10.2174/1573405617666210114142800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/13/2020] [Accepted: 11/12/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Carotid cavernous fistulae (CCF) are rare, and they occur when there is a communication between the internal carotid artery (ICA) and cavernous sinus. These lesions are associated with blunt or penetrating traumatic injuries of the carotid arteries. We present the first cases of cavernous dural arteriovenous fistulae (cDAVF) in the middle meningeal artery (MMA) after the treatment of direct CCF in the ICA with Willis-covered stents (WCSs). CASE PRESENTATION Our patients comprised 22 and 50-year-old males with histories of head injuries months before admission at our facility. In both patients above, cerebral angiography revealed fistulae in the right ICA and left ICA, respectively. They were treated with WCSs via the trans-artery endovascular route. In both cases, the treatments were not in the way attempted via the MMA. Subsequently, they developed cDAVF in the middle meningeal artery (MMA), which were treated with Onyx Liquid Embolic System (Onyx HD-500) (Covidien / ev3 Neurovascular) and conservatively, respectively. CONCLUSION These are the first cases in whom WCSs for the management of direct CCF resulted in cDAVF at the MMA. The WCSs inside the ICA could have resulted in the cDAVF via unknown mechanisms but not iatrogenic.
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Affiliation(s)
- Ting Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, 610041, China
| | - Seidu A Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, 610041, China
| | - Changwei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, 610041, China
| | - Xiaodong Xie
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, 610041, China
| | - Chaohua Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, 610041, China
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Jeong SH, Lee JH, Choi HJ, Kim BC, Yu SH, Lee JI. First line Treatment of Traumatic Carotid Cavernous Fistulas Using Covered Stents at Level 1 Regional Trauma Center. J Korean Neurosurg Soc 2021; 64:818-826. [PMID: 34293848 PMCID: PMC8435656 DOI: 10.3340/jkns.2020.0345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/07/2021] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- Sang Hoon Jeong
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jung Hwan Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hyuk Jin Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung Chul Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Seung Han Yu
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jae Il Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Texakalidis P, Tzoumas A, Xenos D, Rivet DJ, Reavey-Cantwell J. Carotid cavernous fistula (CCF) treatment approaches: A systematic literature review and meta-analysis of transarterial and transvenous embolization for direct and indirect CCFs. Clin Neurol Neurosurg 2021; 204:106601. [PMID: 33774507 DOI: 10.1016/j.clineuro.2021.106601] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/04/2021] [Accepted: 03/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Carotid Cavernous Fistulas (CCFs) are the result of an abnormal communication between the carotid artery and its branches and the venous system of the cavernous sinus. The mainstay of therapy for CCFs consists of transarterial or transvenous embolization, while other treatment options such as open surgery or radiosurgery are still utilized as second-line or adjuvant therapeutic options. OBJECTIVE Our aim was to systematically review and summarize available data regarding short- and long-term outcomes of all available treatment modalities for CCFs. METHODS This systematic review was conducted according to the PRISMA guidelines. A random effects model meta-analysis was conducted. RESULTS Fifty-seven studies comprising 1575 patients were included in this systematic review. Transarterial embolization for direct and indirect CCFs offered a complete obliteration rate of 93.93% (N = 589/627) and 81.51% (N = 119/146), respectively. Transvenous embolization for direct and indirect lesions achieved obliteration in 91.67% (N = 33/36) and 86.03% (N = 425/494) of patients, respectively. Comparison between transarterial and transvenous embolization did not reveal statistically significant differences in terms of fistula obliteration for direct (OR: 1.42; 95% CI: 0.23-8.90; I2 0.0%) and indirect CCFs (OR: 0.62; 95% CI: 0.31-1.23; I2 0.0%). CONCLUSIONS Endovascular embolization techniques are the preferred treatment modality for the management of CCFs. No differences were identified between transarterial and transvenous embolization by synthesizing studies with available data. Future prospective cohorts are warranted to compare the different materials and techniques implemented especially within the rapidly expanding realm of endovascular approaches.
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Affiliation(s)
| | - Andreas Tzoumas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Xenos
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dennis J Rivet
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
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Sharma DP, Kannath SK, Singh G, Rajan JE. Shunt Site Localization of Direct Carotid-Cavernous Fistula Using 3D Rotational Angiography-Utility of Broken-Rim Sign. World Neurosurg 2020; 144:e376-e379. [PMID: 32890847 DOI: 10.1016/j.wneu.2020.08.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Direct carotid-cavernous fistulas (DCCF) develop due to breach in the integrity of the wall of the internal carotid artery, and its localization can sometimes be difficult due to rapid high flow shunts. We hypothesized that 3D rotational angiography could locate the fistula site accurately, where an interrupted rim of the carotid wall would be silhouetted against opacified vascular structures. This finding was described as a broken-rim sign, and in this study, we assessed the utility of this sign in the localization of the shunt point of DCCF. METHODS Retrospective analysis of 15 cases of DCCF was performed, and the rent was characterized based on the broken-rim sign. Two observers independently evaluated the results and compared them against the intraoperative observations. RESULTS The broken-rim sign was identified and correlated with the actual fistula site in 86.6% and 100% of patients by observers 1 and 2, respectively. The inter-rater agreement was 0.87 (P < 0.001). Misinterpretation was made in 2 patients by 1 observer, due to poor contrast opacification of the vascular structures secondary to very rapid shunting and mild movement artifacts. CONCLUSIONS Our study highlights the role of 3D rotational angiogram and analysis of the carotid wall in the localization of the shunt site in DCCF. The broken-rim sign accurately points to the location of the fistula.
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Affiliation(s)
- Dev Prakash Sharma
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute For Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Santhosh Kumar Kannath
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute For Medical Sciences and Technology, Trivandrum, Kerala, India.
| | - Gurpreet Singh
- Achutha Menon Center for Health Science Studies, Sree Chitra Tirunal Institute For Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Jayadevan Enakshy Rajan
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute For Medical Sciences and Technology, Trivandrum, Kerala, India
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Chang S, Young Chung S, Sung Lee D, Suk Park K. Treatment of Carotid Cavernous Fistula Presenting with Contralateral Exophthalmos: Several Experiences of Graft Stent. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:238-242. [PMID: 37501698 PMCID: PMC10370652 DOI: 10.5797/jnet.cr.2019-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/10/2020] [Indexed: 07/29/2023]
Abstract
Objective Graft stent for carotid cavernous fistula (CCF) is known to be a useful treatment. Here, we report our experiences of treatment with graft stents for CCFs. Case Presentations From 2015 through 2018, six patients underwent graft stent placement for CCF occlusion. Clinical and angiographic data were retrospectively reviewed. Access and deployment of a graft stent was successful in all patients and complete occlusion immediately after the procedure or 3-month follow-up angiography. Conclusion Graft stents should be considered as an alternative option of treating CCFs and preserving the parent artery by arterial wall reconstruction especially in patients with a fistula that cannot be successfully occluded with detachable balloons or coils.
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Affiliation(s)
- Sehun Chang
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Do Sung Lee
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Ki Suk Park
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
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Yang H, Li SG, Xiang X, Lv Y, Chu LZ, Peng H, Wang F, Cao H, Liu J. Clinical classification and individualized design for the treatment of basicranial artery injuries. Medicine (Baltimore) 2019; 98:e14732. [PMID: 30882640 PMCID: PMC6426552 DOI: 10.1097/md.0000000000014732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
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.
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Comparison of polyvinyl alcohol copolymer with detachable balloons for the embolisation of direct carotid cavernous fistula: a single-centre experience. Eur Radiol 2017; 27:4730-4736. [DOI: 10.1007/s00330-017-4864-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 04/11/2017] [Accepted: 04/20/2017] [Indexed: 11/27/2022]
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Wajima D, Nakagawa I, Park HS, Yokoyama S, Wada T, Kichikawa K, Nakase H. Successful Coil Embolization of Pediatric Carotid Cavernous Fistula Due to Ruptured Posttraumatic Giant Internal Carotid Artery Aneurysm. World Neurosurg 2016; 98:871.e23-871.e28. [PMID: 27923754 DOI: 10.1016/j.wneu.2016.11.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/25/2016] [Accepted: 11/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The goal of the treatment of direct carotid cavernous fistula (CCF) is to occlude the arteriovenous shunt and to preserve the patency of the concerned internal carotid artery. However, for the ipsilateral posttraumatic fragile cerebrum, coil embolization plus parent artery occlusion for the high-flow direct CCF is better for the prevention of hyperperfusion syndrome and intracranial hemorrhage. We experienced such a case and managed it successfully. CASE DESCRIPTION A 6-year-old boy had severe head trauma caused by being hit by a car. He was transferred to our department and diagnosed as having left acute subdural hematoma and acute brain swelling. Emergent evacuation of hematoma and external decompression were performed. He was treated for severe brain swelling in the intensive care unit for 2 months. Cranioplasty was performed 3 months after the injury. His right hemiparesis and aphasia persisted, so he was transferred to a rehabilitation hospital. However, 2 years after the head injury, he was referred to our department because of abducens nerve palsy. He was diagnosed as having a symptomatic posttraumatic direct CCF, which was caused by a ruptured left cavernous giant internal carotid artery aneurysm. The direct CCF was treated with coil embolization of the giant aneurysm and parent artery occlusion. CONCLUSIONS Coil embolization of the aneurysm and parent artery occlusion for the posttraumatic direct CCF was a good option to manage the abducens nerve palsy and to prevent postoperative hyperperfusion.
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Affiliation(s)
- Daisuke Wajima
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan.
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Hun Soo Park
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Shohei Yokoyama
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Takeshi Wada
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
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Ohlsson M, Consoli A, Rodesch G. Endovascular treatment of carotico-cavernous fistulas with acrylic glue: a series of nine cases. Neuroradiology 2016; 58:1181-1188. [PMID: 27796449 PMCID: PMC5153414 DOI: 10.1007/s00234-016-1760-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 10/20/2016] [Indexed: 11/29/2022]
Abstract
Introduction Injuries to the internal carotid artery close to the cavernous sinus may result in a fistulous connection between the artery and the venous sinus. Symptoms include pulsatile tinnitus, intracranial bruit, ophthalmological symptoms, and risk of intracerebral hematoma in cases of cortical venous reflux. Previous treatment strategies have included detachable latex balloons, coils, covered stents, or combinations thereof. Today, detachable latex balloons are phased out or withdrawn from several markets. Acrylic glue is a proven stable material used for embolization of arteriovenous shunts. It is a precise, fast, and cost-effective method of endovascular embolization, and it does not cause artifacts on MRI or MRA. Methods We treated nine patients suffering from direct fistulas with acrylic glue without any permanent neurological adverse events. Results Four patients were treated with glue embolization of the fistula without occlusion of the parent artery. Five patients with long-lasting symptomatology, large tears in the ICA, and with full collateral cerebral circulation were treated with glue embolization of the fistula and sacrifice of the ICA antero- and retrograde via the ICA and the posterior communicating artery. Conclusion We suggest acrylic glue to be added to the panel of embolic materials used to treat CCFs.
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Affiliation(s)
- Marcus Ohlsson
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, 92151, France. .,Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Arturo Consoli
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, 92151, France
| | - Georges Rodesch
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, 92151, France
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Systematic Analysis of the Risk Factors Affecting the Recurrence of Traumatic Carotid-Cavernous Sinus Fistula. World Neurosurg 2016; 90:539-545.e1. [DOI: 10.1016/j.wneu.2015.12.088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/28/2015] [Accepted: 12/29/2015] [Indexed: 11/20/2022]
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17
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Wendl CM, Henkes H, Martinez Moreno R, Ganslandt O, Bäzner H, Aguilar Pérez M. Direct carotid cavernous sinus fistulae: vessel reconstruction using flow-diverting implants. Clin Neuroradiol 2016; 27:493-501. [PMID: 27129454 PMCID: PMC5719129 DOI: 10.1007/s00062-016-0511-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 03/02/2016] [Indexed: 11/24/2022]
Abstract
Purpose Retrospective evaluation of our experience with the use of flow diverters (FD) for the endovascular treatment of direct carotid-cavernous sinus fistulae (diCCF). Methods Between 2011 and 2015, 14 consecutive patients with 14 diCCF were treated with FD alone or in combination with other implants in a single institution. Results A total of 21 sessions were performed in 14 patients. FD placement was technically successful in all cases without an adverse event. Patients were treated with FD alone (n = 5), FD and covered stents (n = 2), FD and coils (n = 7). A total of 59 FD (24 Pipeline Embolization Device, Medtronic; 35 p64 Flow Modulation Device, phenox), 291 coils, and 3 stent grafts were used. Three of 14 diCCF were completely occluded after the 1st session, a minor residual shunt was found in 7/14, and in the remaining 4/14 patients, the shunt volume was reduced significantly. The mean follow-up period encompassed 20 months. Additional treatment included transvenous coil occlusion (n = 3) and/or further FD deployment (n = 5). An asymptomatic internal carotid artery (ICA) occlusion was encountered in 2 patients, related to an interruption of antiaggregation. At the last follow-up, 10/14 patients were free from ocular symptoms (71 %), 2 had residual exophthalmos, and no patient had clinical deterioration. Conclusion The usage of FD for the treatment of diCCF is straightforward. Injury of the cranial nerves can be avoided. In most cases, ocular symptoms improve. Several FD layers and/or an adjunctive venous coil occlusion are required. Complete occlusion of a diCCF may take weeks or months and long-term antiaggregation is required. In the future, a flexible stent graft might be a better solution.
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Affiliation(s)
- C M Wendl
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany. .,Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Universitätsklinikum Regensburg, Regensburg, Germany.
| | - H Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.,Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
| | - R Martinez Moreno
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - H Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
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Baek JW, Kim ST, Lee YS, Jeong YG, Jeong HW, Baek JW, Seo JH. Recurrent Carotid Cavernous Fistula Originating from a Giant Cerebral Aneurysm after Placement of a Covered Stent. J Cerebrovasc Endovasc Neurosurg 2016; 18:306-314. [PMID: 27847780 PMCID: PMC5104861 DOI: 10.7461/jcen.2016.18.3.306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/29/2016] [Accepted: 09/09/2016] [Indexed: 11/23/2022] Open
Abstract
We report the case of a recurrent carotid cavernous fistula (CCF) originating from a giant cerebral aneurysm (GCA) after placement of a covered stent. A 47-year-old woman presented with sudden onset of severe headache, and left-sided exophthalmos and ptosis. Cerebral angiography revealed a CCF caused by rupture of a GCA in the cavernous segment of the left internal carotid artery. Two covered stents were placed at the neck of the aneurysm. The neurological symptoms improved at first, but were aggravated in the 6 months following the treatment. Contrast agent endoleak was seen in the distal area of the stent. Even though additional treatments were attempted via an endovascular approach, the CCF could not be cured. However, after trapping the aneurysm using coils and performing superficial temporal artery-middle cerebral artery bypass, the neurological symptoms improved. In cases of recurrent CCF originating from a GCA after placement of a covered stent, it is possible to treat the CCF by endovascular trapping and surgical bypass.
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Affiliation(s)
- Jung Wook Baek
- Department of Neurosurgery, Busan Paik Hospital, Inje University, School of Medicine, Busan, Korea
| | - Sung Tae Kim
- Department of Neurosurgery, Busan Paik Hospital, Inje University, School of Medicine, Busan, Korea
| | - Young Seo Lee
- Department of Neurosurgery, Busan Paik Hospital, Inje University, School of Medicine, Busan, Korea
| | - Young-Gyun Jeong
- Department of Neurosurgery, Busan Paik Hospital, Inje University, School of Medicine, Busan, Korea
| | - Hae Woong Jeong
- Department of Diagnostic Radiology, Busan Paik Hospital, Inje University, School of Medicine, Busan, Korea
| | - Jin Wook Baek
- Department of Diagnostic Radiology, Busan Paik Hospital, Inje University, School of Medicine, Busan, Korea
| | - Jung Hwa Seo
- Department of Neurology, Busan Paik Hospital, Inje University, School of Medicine, Busan, Korea
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