Endovascular treatment of carotid cavernous sinus fistula: A systematic review

Deconstructive repair of a direct carotid-cavernous fistula via a posterior circulation retrograde approach

We report a case of a 24-year-old patient who presented after a head trauma with a traumatic occlusion of his left internal carotid artery. He underwent diagnostic cerebral angiogram and was found to have a direct left carotid-cavernous fistula (CCF) with retrograde filling from the posterior circulation across the posterior communicating artery. Because of the severe injury to the left internal carotid artery (ICA), reconstructive repair of the ICA was not possible. The patient underwent deconstructive repair of the CCF by coil embolization using a posterior retrograde approach. Coils were successfully placed in the cavernous sinus and back into the left ICA with complete cure of the CCF and restoration of cerebral perfusion distal to the treated CCF. We review the types of CCFs, their clinical presentation, and their endovascular treatments. Retrograde access of a direct CCF is rarely reported in the literature, and we believe this approach offers a viable alternative in appropriately selected patients.

The use of PK Papyrus covered coronary stent for carotid reconstruction: an initial institutional experience

BACKGROUND

The use of covered stent grafts for the treatment of carotid rupture is increasingly being used given their ability to preserve the parent artery while simultaneously occluding the fistula or rupture point.

METHODS

This case series describes the technical feasibility of using, and the performance of, the PK Papyrus covered coronary stent (Biotronik, Inc., Lake Oswego, Oregon, USA) in six patients with carotid rupture, including carotid cavernous fistulas, between July 2021 and October 2023 in a single-center institution in the USA.

RESULTS

The median decade of life was 5 (IQR 3) with a 1:1 male-to-female ratio. The majority were black patients (n=5/6, 83.3%). The most common disease pathology was carotid cavernous fistula (n=4/6, 66.7%), followed by traumatic carotid rupture (n=2/6, 33.3%). All the stent embolization procedures were successfully treated with the PK Papyrus covered coronary stent. None of the patients had any recurrence or re-treatment. The number of stents required ranged from 1 to 3. A balloon guide catheter was used in 66.7% of cases (n=4/6). In-hospital mortality was 0.0% (n=0/6). No in-stent thrombosis was observed, but there was one case of cangrelor-associated hemorrhagic stroke conversion. Transfemoral access was used in all cases with one access site complication. Median follow-up time was 1.8 months (IQR 3.5).

CONCLUSIONS

To our knowledge, this is the largest case series in the USA demonstrating the feasibility and safety of using the PK Papyrus covered coronary stent for the treatment of carotid rupture, including carotid cavernous fistulas.

Embolization of indirect carotid cavernous fistulas via the vein of Labbé using contralateral approach

In our report, we present the case of a 60-year-old adult with symptomatic indirect carotid-cavernous fistulas (CCFs). All venous outflow routes from the cavernous sinus were absent except for an engorged left superficial middle cerebral vein, which extended through the left vein of Labbé to the left transverse sinus and then to right transverse-sigmoid sinus. We approached the diseased cavernous sinus retrogradely, starting from the right femoral vein and passing through the right transverse-sigmoid sinus, left transverse sinus, and left vein of Labbé, ultimately reaching the left CCFs. Embolization was performed using coils, successfully obliterating the fistulas without complications. This case represents the second reported approach through the vein of Labbé for CCFs and the first using a trans-Labbé vein from a contralateral approach (video 1), proving advantageous by avoiding an acute angle between the vein of Labbé and the ipsilateral sigmoid sinus.1-6neurintsurg;jnis-2024-022311v1/V1F1V1Video 1Embolization of CCF using a Trans-Labbé vein from a contralateral approach.‍.

Delayed Pontomesencephalic and Cervical Cord Venous Drainage Followed by Contralateral Carotid-Cavernous Fistula after Craniofacial Fractures: A Case Report

A 24-year-old male was admitted with progressive cervical hypesthesia, tetraparesis, dyspnea, and a history of craniofacial fracture. Spinal magnetic resonance imaging (MRI) showed brainstem edema extending to the thoracic spine with multiple prominent perimedullary vascular structures. Cerebral digital-substraction angiography revealed Barrow type A carotid-cavernous fistula. Total occlusion with preservation of internal carotid artery flow was achieved using 1 detachable balloon and 6 coils. Postoperatively, immediate respiratory recovery, gradual extremities strength improvement, and right abducens nerve palsy were found. One month follow-up cervical MRI showed good recovery of spinal cord edema and perimedullary veins.

Endovascular approaches for the treatment of dural carotid-cavernous fistulas: A systematic review

INTRODUCTION

Dural carotid-cavernous fistulas (dCCFs), also known as indirect carotid-cavernous fistulas, represent abnormal connections between the arterial and venous systems within the cavernous sinus that are typically treated via endovascular approach. We aim to investigate the clinical characteristics of patients with dCCFs based on the endovascular treatment approach and assess angiographic and clinical outcomes.

METHODS

A systematic review of the literature was performed. Data including number of patients, demographics, presenting clinical symptoms, etiology of fistula, Barrow classification, and embolization material were collected and evaluated. Outcome measures collected included degree of fistula occlusion, postoperative symptoms, complications, and mean follow-up time.

RESULTS

A total of 52 studies were included examining four primary endovascular approaches for treating dCCFs: transarterial, transfemoral-transvenous (transpetrosal or other), transorbital (percutaneous or via cutdown), and direct transfacial access. Overall data was collected from 736 patients with 817 dCCFs. Transarterial approaches exhibit lower dCCF occlusion rates (75.6%) compared to transvenous techniques via the inferior petrosal sinus (88.1%). The transorbital approach via direct puncture or surgical cutdown offers a more direct path to the cavernous sinus, although with greater complications including risk of orbital hematoma. The direct transfacial vein approach, though limited, shows up to 100% occlusion rates and minimal complications.

CONCLUSION

We provide a comprehensive review of four main endovascular approaches for dCCFs. In summary, available endovascular treatment options for dCCFs have expanded and provide effective solutions with generally favorable outcomes. While the choice of approach depends on individual patient factors and technique availability, traditional transvenous procedures have emerged as the first-line endovascular treatment. There is growing, favorable literature on direct transorbital and transfacial approaches; however, more studies directly comparing these general transvenous options are necessary to refine treatment strategies.

Imaging of cerebrovascular complications from blunt skull base trauma

Cerebrovascular complications from blunt trauma to the skull base, though rare, can lead to potentially devastating outcomes, emphasizing the importance of timely diagnosis and management. Due to the insidious clinical presentation, subtle nature of imaging findings, and complex anatomy of the skull base, diagnosing cerebrovascular injuries and their complications poses considerable challenges. This article offers a comprehensive review of skull base anatomy and pathophysiology pertinent to recognizing cerebrovascular injuries and their complications, up-to-date screening criteria and imaging techniques for assessing these injuries, and a case-based review of the spectrum of cerebrovascular complications arising from skull base trauma. This review will enhance understanding of cerebrovascular injuries and their complications from blunt skull base trauma to facilitate diagnosis and timely treatment.

Covered Stent Treatment for Direct Carotid-Cavernous Fistulas: A Meta-Analysis of Efficacy and Safety Outcomes

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.

Evaluating the diagnostic performance of non-contrast magnetic resonance angiography sequences in the pre-procedural comprehensive analysis of direct carotid cavernous fistula

PURPOSE

Endovascular treatment of direct carotid cavernous fistula (DCCF) requires invasive diagnostic cerebral angiography for diagnosis and planning; however, a less invasive modality like magnetic resonance angiography (MRA) can be useful, especially in high-risk cases. This single-centre study evaluated a newer MR angiography (MRA) sequence, silent MRA and the traditional time of flight (TOF) MRA for pre-procedural treatment planning of DCCF.

METHODS

All consecutive DCCF patients who underwent TOF, silent MRA and diagnostic cerebral angiography were included in the study. Angiographic features like rent size, location, draining veins and collateral communicating arteries were analysed and compared between the two MRA sequences, with digital subtraction angiography (DSA) as the gold standard.

RESULTS

Fifteen patients were included in the study. TOF MRA exhibited better sensitivity (76.9% vs 69.2%) in identifying the rent location, correctly pinpointing the location in 93.3% compared to 73.3% with silent MRA. Both MRA sequences showed good agreement with DSA for primary sac and rent size. TOF MRA correctly identified 86.2% of 210 total venous structures compared to 96% by silent MRA. Silent MRA demonstrated higher sensitivity (90% vs 76%) and accuracy (87.69 vs 94.36) in visualisation of involved veins compared to TOF MRA.

CONCLUSION

Arterial characteristics of DCCF like rent location and rent size were better assessed by TOF MRA. Although both MRA identified venous features, silent MRA correlated better with DSA irrespective of the size and proximity to the site of the fistula. Combining both sequences can evaluate various angioarchitectural features of DCCF useful for therapeutic planning.

Neuro-Ophthalmic Manifestations of Carotid Cavernous Fistulas: A Systematic Review and Meta-Analysis

Carotid-cavernous fistulas (CCFs) are pathologic, arteriovenous communications between the carotid artery and cavernous sinus. They cause various complex neuro-ophthalmic symptoms by shunting the flow of arterial blood into the venous system. In this study, a systematic review is conducted on the neuro-ophthalmic presentations associated with CCFs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines were followed during the systematic review. We searched PubMed, Scopus, and Web of Science from inception to December 31, 2023. Articles written in English on patients with confirmed CCFs reporting clinical features, diagnostic modalities, treatment approaches, and outcomes were included. Abstracted data included demography, clinical presentations, venous flow dynamics, trauma history, investigative methodology, approaches to treatment, and outcomes. Overall, 33 studies with a total number of 403 patients were included. The mean age at presentation was 42.99 years for patients with direct CCFs and 55.88 years for those with indirect CCFs. Preponderance was observed in male patients with direct CCFs, constituting 51.56%, while females predominated in those with indirect CCFs, at 56.44%. The clinical symptoms in all patients with CCFs were proptosis in 58 cases (14.39%), conjunctival congestion in 29 patients (7.20%), diplopia in nine patients (2.23%), vision blurring in four patients (0.99%), eyelid swelling in five patients (1.24%), pain in the eye in three patients (0.74%), and an upper lid mass in one patient (0.25%). Endovascular treatments, including coil and Onyx embolization, have been effective in relieving clinical symptoms and arresting the progression of these symptoms. In conclusion, the common clinical features in CCFs usually underline proptosis, congestion, and diplopia, necessitating a comprehensive neuro-ophthalmological review. Prompt identification of the symptoms of blurred vision is crucial to avoid permanent damage. Lid swelling, ocular pain, and an upper lid mass are less common but equally essential presentations for comprehensive evaluation. The recognition of these variable presentations is essential not only for timely intervention but also for the improvement in patient outcomes, thus emphasizing the role of clinician awareness in managing CCF cases.

Surgical management of glaucoma secondary to indirect carotid-cavernous fistula: A case report

INTRODUCTION

Indirect carotid-cavernous fistula (CCF) can lead to secondary glaucoma, posing significant treatment challenges. This paper discusses a case where standard embolization failed, and an Ahmed FP7 valved glaucoma tube shunt was crucial for managing the increased intraocular pressure (IOP), highlighting the necessity for individualized surgical approaches.

CASE PRESENTATION

A 48-year-old female presented in the emergency department with conjunctival hyperemia, proptosis and elevated IOP; initial imaging findings were indicative of orbital inflammatory disease. Further evaluation with cerebral CT angiography revealed a possible CCF. Subsequent angiography confirmed an indirect CCF type D, leading to the patient undergoing endovascular embolization. Final monitoring revealed a subtotal occlusion of the fistula. Although there was some improvement post-procedure, IOP remained elevated despite medication, and subsequent attempts of embolization were unsuccessful. Surgical intervention with a tube shunt was performed, allowing IOP to decreased to a normal range. Optic nerve head optical coherence tomography, standard automated perimetry, and best-corrected visual acuity remained stable during the 33-month follow-up.

DISCUSSION

In managing glaucoma linked to CCF, a multidisciplinary approach is critical. Conservative methods are often adequate, with spontaneous CCF closure observed in a significant percentage. Endovascular embolization is reserved for refractory cases, with embolization showing a higher rate of IOP normalization compared to medication alone. Yet, when fistula closure is challenging or contraindicated, individualized management strategies like glaucoma surgery may be employed.

CONCLUSIONS

When fistula closure is not achievable, the Ahmed FP7 valved tube shunt can successfully regulate IOP with minimal complications, providing an effective alternative for refractory cases.

The Basal or Sphenopetrosal Superficial Middle Cerebral Vein Type

Background and Objectives: The adult superficial middle cerebral vein (SMCV) commonly drains into the middle cranial fossa. However, different embryonic types persist, in which the SMCV drains into the lateral sinus. The basal type of SMCV coursing on the middle fossa floor is a scarce variant. Materials and Methods: During a retrospective study of archived computed tomography angiography (CTA) and magnetic resonance angiography (MRA) files, three rare adult cases of the basal or sphenopetrosal type of SMCV were found and further documented. Results: In the first case, which was evaluated via CTA, the basal type of SMCV formed a sagittal loop. It continued on the middle fossa floor, over a dehiscent tegmen tympani, to drain into the lateral sinus. In the second case, documented via MRA, the basal type of SMCV's anterior loop was in the coronal plane and closely related to the internal carotid artery and the cavernous sinus. It continued with the basal segment over a dehiscent glenoid fossa of the temporomandibular joint (TMJ). In the third case, documented via CTA, the initial cerebral part of the SMCV had a large fenestration. The middle fossa floor coursed within a well-configured sulcus of the SMCV and received a tributary through the tympanic roof. Its terminal had a tentorial course. Conclusions: Beyond the fact that such rare variants of the SMCV can unexpectedly interfere with specific approaches via the middle fossa, dehiscences of the middle fossa floor beneath such variants can determine otic or TMJ symptoms. Possible loops and fenestrations of the SMCV should be considered and documented preoperatively.

The importance of the oral and maxillofacial surgery and traumatology team in the diagnosis of a cavernous carotid fistula: Case report

Due to the anatomical proximity between the skull and the face, maxillofacial trauma can often cause injuries to cranial structures. Among these complications are carotid-cavernous fistulas (CCF), which are rare in maxillofacial trauma, although their etiology is usually traumatic. They are described as an atypical communication between the internal carotid artery and the cavernous sinus, which can generate a sudden change in the direction and distribution of blood flow between the brain and orbit. This paper aims to report a case of craniomaxillofacial trauma in which the patient evolved with diplopia, palpebral ptosis, and ophthalmoplegia of the left eye, diagnosed as traumatic CCF. The oral and maxillofacial surgery and traumatology team of the University Hospital of Western Paraná was observed these symptoms for the first time during post-operative follow-up after one day of surgery to repair mandibular fractures of the patient in question. With the identifying the signs and symptoms, a neurosurgery was requested for assessment and management. After clinical evaluation and imaging tests, they diagnosed the condition as CCF 5 days after the mandibular fractures and the patient was referred for treatment. Surgery was performed, in the same day, to resolve the CCF with the endovascularly by embolization with micromoles. The CCF was resolved and the patient continued on outpatient follow-up, progressing without sequelae from the CCF or mandibular fractures.

Intermittent Manual Carotid Compression as a Treatment Option for Indirect Low Flow Carotid Cavernous Fistula

PURPOSE

To evaluate the efficacy of intermittent manual carotid compression (IMCC) in the management of low-flow carotid cavernous fistulae (CCF).

MATERIALS AND METHODS

Patients diagnosed with low-flow CCF and treated with IMCC over a period of 13 years were retrospectively analyzed. Data analyzed included demographic details, clinical features, type of CCF, and response to therapy. Outcomes were categorized as complete cure, partial cure, and no cure or worsening. Patients with complete and partial cure were grouped as good outcome whereas those with no cure or worsening as poor outcome.

RESULTS

A total of 44 patients were advised IMCC for low-flow CCF, of whom five were lost to follow-up. Results of the remaining 39 patients were analyzed, of whom 21 (53.8%) were males. The mean age at presentation was 54.38 ± 14.54 years. The median duration between the onset of symptoms and presentation was 5.0 ± 4.10 months. The common presenting features were episcleral congestion and proptosis (89.7%), extraocular motility restriction (66.7%), and diplopia (48.7%). Most common CCF type was type D (34, 87.2%). All patients were advised to undergo IMCC. Good outcome was seen in 35 patients (89.7%, 95% CI: 80.2% to 99.2%), whereas poor outcome was seen in four (10.3%) patients. The mean duration of follow-up was 15.91 ± 21.87 months.

CONCLUSION

The present study found a good outcome with IMCC in 89.7% cases of indirect low-flow CCF with no major complications. It should be considered the management of choice in patients who are systemically unfit or cannot afford endovascular embolization.

Case report: Delayed quadriplegia from traumatic carotid cavernous fistula: a rare case with perimedullary venous drainage

Background

Carotid cavernous fistula (CCF) refers to the abnormal arteriovenous communication between the carotid system at the skull base and the sphenoid cavernous sinus, which is caused by trauma in almost 75% of cases. The drainage of venous blood to the spinal cord represents a distinctive mechanism, which is commonly observed in dural arteriovenous fistula (DAVF), and typically manifests clinically as progressive myelopathy. However, it is a rare occurrence in clinical practice that traumatic carotid cavernous fistula (TCCF) causes delayed quadriplegia through perimedullary venous drainage.

Case presentation

We report the case of a 29-year-old male patient who was admitted to the hospital with a sudden onset of headache and quadriplegia. The patient had previously lost his right eye in a traffic accident 5 years ago. Cerebral angiography showed a high-flow direct CCF on the right side, accompanied by obvious drainage of cerebellar and perimedullary veins. We successfully performed coil embolization for the CCF, and the symptoms of the patient gradually improved after the operation. During follow-up at sixth-months, the patient regained the ability to walk independently.

Conclusion

We experienced a rare case of TCCF with quadriplegia. Utilizing coil embolization, we achieved successful improvement in the patient's condition. However, the mechanism and the best treatment of CCF drainage through the perimedullary vein are still unclear. We need to further explore the pathophysiological information of CCF venous drainage.

Percutaneous transjugular approach without arterial monitoring for the treatment of a direct carotid-cavernous fistula with vascular Ehlers-Danlos syndrome: illustrative case

BACKGROUND

Vascular Ehlers-Danlos syndrome (vEDS) because of COL3A1 mutations is a rare inherited collagen vascular disease associated with spontaneous arterial dissections, aneurysms, vessel rupture, and organ rupture. A direct carotid-cavernous fistula (CCF) is the most common central nervous system vascular anomaly in vEDS; however, its treatment is challenging due to extremely fragile arteries and veins.

OBSERVATIONS

A 22-year-old woman presented with pulsatile tinnitus and mild diplopia. CCF formation without trauma, cervical dissecting aneurysms, thin skin, and multiple ligament tears, as well as a genetic analysis, led to a diagnosis of vEDS. To minimize the risk of vascular injury in the thoracoperitoneal cavity, the internal jugular vein was directly punctured and the CCF was embolized transvenously using the triple-overlay road-mapping technique without arterial monitoring. The CCF was completely occluded, and the patient showed an excellent clinical course without neurological or vascular complications.

LESSONS

Physicians and neurosurgeons should consider vEDS when treating younger patients with spontaneous CCF without trauma and investigate the possibility of genetic abnormalities and systemic vascular pathology. Transvenous embolization of a CCF through the transjugular route using the triple-overlay road-mapping technique can minimize the risk of vascular injury in a patient with vEDS.

Venous outflow-targeted coil embolization of direct carotid-cavernous fistulas

BACKGROUND

Coil embolization is the mainstay treatment for carotid-cavernous fistulas (CCFs). However, few studies have reported entire occlusion of engorged veins to interrupt venous outflow. We report our experience with venous outflow-targeted coil embolization of direct CCFs.

METHODS

We retrospectively reviewed all the patients diagnosed with direct CCFs treated with venous outflow-targeted coil embolization between November 2013 and February 2020. Venous outflow-targeted coil embolization of the CCFs was performed as follows. First, transarterial stent-assisted coil embolization of CCFs was performed. If the venous outflow to the engorged veins persisted after transarterial stent-assisted coil embolization, entire occlusion of the engorged veins and additional coil packing within the cavernous sinus were performed to interrupt the venous outflow.

RESULTS

Ten patients had undergone venous outflow-targeted coil embolization, 6 women (60%) and 4 men (40%). Transfemoral cerebral angiography showed high-flow, direct CCFs in all the patients. Venous outflow occurred through the superior ophthalmic vein (SOV) in all the patients and was completely interrupted by the entire occlusion of the engorged veins with fibered coils. Three patients (30%) had undergone additional treatment in a supplementary manner because of recurrent symptoms (chemosis in 1 patient, faint tinnitus in 2 patients) in the early postprocedural period (1 to 4 weeks). All the symptoms were resolved on follow-up. No additional recurrence was found during follow-up (1-75 months). No peri-procedural complications were encountered.

CONCLUSIONS

Venous outflow-targeted coil embolization of CCFs would be a safe and effective treatment method.

A case report of multi-step management of extracranial carotid artery aneurysm and carotid-cavernous fistula combination in patients

Extracranial carotid artery aneurysms (ECAA) and carotid-cavernous fistulas (CCF) are rare arterial pathologies with severe complications and increased risk of mortality. The optimal treatment approach for this combined condition is a topic of debate among neurosurgeons and neuroradiologists, and a standardized treatment protocol has yet to be established. The aim of this case report was to demonstrate the management of a rare combination of ECAA and CCF in patients. The treatment strategy included a two-step procedure of endovascular embolization of CCF followed by dual antiplatelet therapy and endovascular stenting of an aneurysm. Control angiograms showed the exclusion of an aneurysm from the blood circulation and CCF symptoms were resolved.

Neuropsychiatric Presentation in Indirect Carotid-Cavernous Fistula: A Case Report

Carotid-cavernous fistula (CCF) is a rare sight and potentially life-threatening disorder arising from an abnormal connection between the carotid artery and the cavernous sinus. It can be classified into direct or indirect according to different arteriovenous shunts. Direct CCF usually has dramatic ocular presentations, whereas indirect CCF has a more insidious course and may be associated with neurologic symptoms in posteriorly draining fistulas. A 61-year-old gentleman presented with five days history of altered behavior and double vision preceding a bulging left eye. Ocular examination showed left eye proptosis, generalized chemosis, total ophthalmoplegia, and raised intra-ocular pressure. Computed tomography angiography (CTA) brain and orbit demonstrated dilated superior ophthalmic vein (SOV) with communication to a tortuous cavernous sinus suggestive of carotid-cavernous fistula (CCF). Digital subtraction angiography (DSA) eventually confirmed the presence of indirect communication between branches of the bilateral external carotid artery (ECA) and left cavernous sinus, which is a type C indirect CCF according to the Barrow classification. Total embolization of left CCF was successfully achieved via transvenous access. A marked reduction of proptosis and intra-ocular pressure was noted following the procedure. Although rare, neuropsychiatric presentation could be a possible presentation of CCF, and treating physicians should be aware of it. A high index of suspicion and prompt diagnosis is crucial in managing this sight and life-threatening condition. Early intervention can improve the prognosis of patients.

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

Background

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

Results

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

Conclusions

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

Efficiency of endovascular management with a combination of Onyx and coils for direct and indirect carotid cavernous fistula treatment: experience of a single center

BACKGROUND

To evaluate the safety and efficacy of endovascular treatment with a combination of Onyx and coils for carotid cavernous fistulas (CCFs), and to characterize the factors associated with clinical and angiographic outcomes for direct and indirect CCFs.

METHODS

This retrospective study included 31 patients with CCF treated with an endovascular procedure between December 2017 and March 2022.

RESULTS

Direct and indirect CCFs were found in 14 (45.2%) and 17 (54.8%) cases, respectively. Direct CCFs included eleven traumatic carotid cavernous fistulas. The most common symptom on admission was chemosis, which was seen in 17 (54.8%) patients. Eight (25.7%) cases were treated by the transarterial approach. Fourteen (45.2%) cases were treated using the femoral vein-inferior petrosal sinus approach. Seven (22.6%) were treated by direct puncture of the superior ophthalmic vein. Two (6.5%) were treated by the femoral vein-facial vein approach. Immediate complete occlusion and follow-up rates were 93.5% and 96.7%, respectively. Twenty-nine (96.7%) patients experienced an improvement in their symptoms at clinical follow-up. Chemosis was significantly improved or resolved in 15 patients. Ophthalmoplegia was improved or resolved in 10 patients. Visual impairment was improved in 6 patients. Proptosis was improved or resolved in 5 patients. One case (3.2%) experienced procedure-related complication presented with transient oculomotor nerve palsy. In univariate subgroup analysis, use of balloon, treatment approach, and history of head trauma were significantly different between the direct and indirect CCF groups.

CONCLUSIONS

Endovascular treatment with a combination of Onyx and coils is a safe and effective therapy for CCFs. In this study, the transarterial approach was a favorable option for embolization of direct CCFs. In contrast, the transvenous approach may be the first choice of treatment for indirect CCFs.

Outcomes After Endovascular Treatment of Direct Carotid Cavernous Fistulas: Systematic Review and Meta-Analysis

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.

Carotid cavernous fistula: A rare but treatable cause of ophthalmoplegia - A case report

Carotid cavernous fistulas (CCFs) are a rare but debilitating entity that may present with orbital or cerebral venous hypertension. CCFs may pose diagnostic and management pitfalls for clinicians as they can initially be misdiagnosed as primary orbital pathology or nonarteriovenous shunting-related cavernous sinus pathology. Furthermore, the resolution of pulsatile tinnitus could be an ominous sign in patients with untreated dural arteriovenous fistula. We describe a case of a 56-year-old male who presented with progressive right eye proptosis, congestion, decreased visual acuity, limited duction, exophthalmos, and pulsatile tinnitus. The patient had poor response to antibiotics and steroids. Magnetic resonance imaging brain showed significant inflammation involving the right orbit and atypical enhancement of the basal frontal lobe adjacent to the orbit. Cerebral angiography revealed an indirect right CCF and right sigmoid sinus thrombosis with stenosis of the right internal jugular vein. No clear predisposing factor was identified. Given the rapidly progressive nature of the condition, the patient successfully underwent endovascular treatment with transvenous approach to preserve flow in the internal carotid artery while ensuring occlusion of the fistula. A triad of proptosis, eye congestion, and signs of turbulent flow such as tinnitus or orbital bruit should raise suspicion for CCF. An interesting feature in this patient is that CCF may have occurred secondary to sigmoid sinus thrombosis with accompanying small cortical vein drainage. Our case highlights the importance of early recognition and timely intervention to ensure the resolution of orbital hypertension-related symptoms in rare cases of CCFs.

Usefulness of a Curved Multiple Reconstruction Image for Transarterial Intravenous Coil Embolization of a Dural Arteriovenous Fistula of the Sphenobasal Vein: A Case Report

Hemorrhagic isolated dural arteriovenous fistulas (DAVFs) are often challenging to treat. Here, we report a case of the lateral cavernous sinus (CS) DAVF successfully treated by transarterial intravenous coil embolization using a curved multiplanar reconstruction (MPR) image assistance. A 54-year-old man presented with a severe headache and was diagnosed with subarachnoid hemorrhage caused by CSDAVF. Angiography indicated that the fistula was fed by branches of the left external carotid artery and drained into cortical veins. There were multiple shunting points at the left sphenobasal vein accompanied by varicose veins. Using curved MPR images, the left accessory meningeal artery was chosen for the endovascular approach into the affected veins, including ruptured varix. The shunt was completely occluded by detachable coils.

When the curved MPR image indicates a developing feeding artery and a large shunting point, transarterial intravenous coil embolization becomes a good treatment option for CSDAVF, which has no venous access.

First reported single-surgeon transpalpebral hybrid approach for indirect cavernous carotid fistula: illustrative case

BACKGROUND

Failure to reach the cavernous sinus after multiple transvenous attempts, although rare, can be challenging for neurointerventionists. The authors sought to demonstrate technical considerations and nuances of the independent performance of a novel hybrid surgical and endovascular transpalpebral approach through the superior ophthalmic vein (SOV) for direct coil embolization of an indirect carotid cavernous fistula (CCF), and they review salient literature regarding the transpalpebral approach.

OBSERVATIONS

An illustrative case, including patient history and presentation, was reviewed. PubMed, MEDLINE, and Embase databases were searched for articles published between January 1, 2000, and September 30, 2021, that reported ≥1 patient with a CCF treated endovascularly via the SOV approach. Data extracted included sample size, treatment modality, surgical technique, performing surgeon specialty, and procedure outcome. The authors’ case illustration demonstrates the technique for the hybrid transpalpebral approach. For the review, 273 unique articles were identified; 14 containing 74 treated patients fulfilled the inclusion criteria. Oculoplastic surgery was the most commonly involved specialty (5 of 14 studies), followed by ophthalmology (3 of 14). Coiling alone was the treatment of choice in 12 studies, with adjunctive use of Onyx (Medtronic) in 2.

LESSONS

The authors’ technical case description, video, illustrations, and review provide endovascular neurosurgeons with a systematic guide to conduct the procedure independently.

A Case of a Carotid Cavernous Fistula

Case Presentation: A 73-year-old male presented to the emergency department complaining of pain in his right eye for four weeks. He denied any trauma, and the pain was accompanied by ptosis, proptosis, swelling, redness, blurred vision, and a frontal headache. On examination, conjunctival arterialization was also appreciated. Magnetic resonance imaging and angiography showed evidence of a carotid cavernous fistula for which the patient underwent successful transvenous coiling and embolization. Discussion: Carotid cavernous fistulas are classified as higher flow, direct fistulas or lower flow, indirect fistulas; the latter is more insidious in onset. Classic symptoms include conjunctival arterialization, proptosis, ptosis, palpebral edema, ocular palsy, vibratory sensation, elevated intraocular pressure without pupillary or visual acuity deficits, and headache. The treatment of choice is transvenous embolization.

Correlation of Clinical Presentations and Imaging Findings with Flow Dynamics in Carotid-Cavernous Fistula Patients at Dr. Hasan Sadikin Hospital, Bandung

Background: Carotid cavernous fistulas (CCFs) have variable clinical presentation, imaging, and angiographic findings. The study aims to investigate the association of clinical presentations and radiological findings with flow dynamics from digital subtraction angiography (DSA) of CCFs patients. Methods: CCF patients who underwent DSA at Dr. Hasan Sadikin general hospital from January 2017 – December 2019 were included in this study. Patient’s characteristics, clinical presentations, and imaging results were retrieved from the patient’s medical record and radiology database. Fractures, proptosis, extraocular muscle thickening, superior ophthalmic vein dilatation, cavernous hyperdense lesion, and infarct are expected to be identified from imaging results. DSA identified types of flow dynamic based on Barrow classification and venous drainage patterns. Numeric data were analyzed by using Mann Whitney test, while categorical data were analyzed with Fisher’s exact test. Results: Twenty-eight patients were included in the study, with patients’ mean age was 30.5-year-old (range: 14- to 61-year-old), consisting of 19 males (67.9%) and 9 females (32.1%). In approximately 75% of the cases, the cause of CCF was a history of trauma. Patients with high flow CCFs were associated with the findings of cavernous sinus hyperdense and proptosis than patients with low flow. Patients who are presented with more than 1-year-long duration of symptoms were more likely to have more than 1 draining vein, compared to patients who are presented with < 1-year-long duration of symptoms. Conclusions: History of trauma, longer duration of symptoms, and the presence of a hyperdense cavernous lesion on head CT scan results require further angiographic study prior to endovascular intervention.

Radiation Dose and Fluoroscopy Time of Endovascular Coil Embolization in Patients with Carotid Cavernous Fistulas

Carotid cavernous fistulas (CCFs) are abnormal connections between the cavernous sinus and the internal and/or external carotid artery. Endovascular therapy is the gold standard treatment. In the current retrospective single-center study we report detailed dosimetrics of all patients with CCFs treated by endovascular coil embolization between January 2012 and August 2021. Procedural and dosimetric data were compared between direct and indirect fistulas according to Barrow et al., and different DSA protocol groups. The local diagnostic reference level (DRL) was defined as the 3rd quartile of the dose distribution. In total, thirty patients met the study criteria. The local DRL was 376.2 Gy cm². The procedural dose area product (DAP) (p = 0.03) and the number of implanted coils (p = 0.02) were significantly lower in direct fistulas. The median values for fluoroscopy time (FT) (p = 0.08) and number of DSA acquisitions (p = 0.84) were not significantly different between groups. There was a significantly positive correlation between DAP and FT (p = 0.003). The application of a dedicated low-dose protocol yielded a 32.6% DAP reduction. In conclusion, this study provides novel DRLs for endovascular CCF treatment using detachable coils. The data presented in this work might be used to establish new specific DRLs.

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

INTRODUCTION

Carotid cavernous fistulas (CCFs) are rare, usually follow head trauma or aneurysmal rupture. Recent treatment options include endovascular techniques such as flow diversion devices (FDDs).

OBJECTIVE

To present our case treated with FDD application with transarterial cavernous-sinus coiling and present a systematic review on the use and effectiveness of FDDs in CCF treatment.

MATERIALS AND METHODS

We present our case of CCF treatment with FDD. A search was also conducted in PubMed, EMBASE and Cochrane until November 2020. Reference lists were also cross-checked.

RESULTS

Including our case, thirty-eight patients were identified with a CCF that was treated with FDDs in sixteen studies. Twenty-two patients were females, nine were males and the rest unidentified. The mean age was 52,6 years (range 17-86, SD± 19.28). Thirty-six patients suffered from direct and two from indirect CCFs. Single FDD was used in four cases, single FDD with embolic materials in eleven cases, multiple overlapping FDDs were used in six cases and multiple overlapping FDDs with embolic materials were used in seventeen cases. Thirty-five patients (92,1%) had clinical improvement, immediate angiographic occlusion was seen in 44,7% of the cases, while long-term occlusion rate was 100% but with variable follow-up periods. One patient (2,6%) presented with a neurological deficit related to FDD deployment.

CONCLUSION

Targeted treatment of CCFs with single or overlapping FDDs with or without adjunct embolic agents offers a high success rate, both clinically and long-term angiographically compared to other endovascular methods alone. However, further research with multi-center prospective trials is warranted.

Transfemoral transvenous embolization through the vein of Trolard and superficial middle cerebral vein for cavernous sinus dural arteriovenous fistula with isolated cortical vein drainage: A case report and literature review

Background:

Endovascular treatment may be challenging for cavernous sinus dural arteriovenous fistulas (CSDAVFs) with prominent leptomeningeal drainage without other accessible routes. We report a case of CSDAVF with isolated cortical venous successfully drainage treated by percutaneous transvenous embolization through the vein of Trolard and superficial middle cerebral vein (SMCV). We also review the literature of CSDAVFs treated by transvenous embolization through SMCV with or without combined surgical approach.

Case Description:

A 46-year-old woman presented with ocular symptoms and delayed treatment was encountered due to the COVID-19 pandemic. Cerebral angiography showed a CSDAVF (Barrow type D, Borden II, and Cognard II a + b) with isolated cortical vein drainage. Percutaneous transvenous access to the fistula through the inferior petrosal sinus was attempted but failed. Transvenous embolization through the vein of Trolard and SMCV was further attempted, and satisfactory occlusion of the fistula was achieved with detachable coils. This access route was chosen because of the occlusion of other access routes and can obliterate the need for more invasive approach, that is, combined surgical and endovascular approach. Cerebral angiography obtained 6 months following the procedure, confirmed complete angiographic obliteration of the fistula. The patient made an uneventful recovery.

Conclusion:

To avoid invasive combined surgical and endovascular approach, transvenous embolization through the vein of Trolard and SMCV may be another accessible option for treating CSDAVF with isolated cortical venous drainage.

Cavernous Sinus Dural Arteriovenous Fistula in a Patient with Thyroid-Associated Ophthalmopathy: Complete Resolution after Medical Treatment

Thyroid-associated ophthalmopathy (TAO) is a well-known and frequent epiphenomenon of a hyperthyroid autoimmune disease that can present with proptosis, strabismus, and diplopia. Ophthalmopathy can occur in the absence of overt Graves’ disease, even in euthyroid patients. Cavernous sinus dural fistulas (CS-DAVF) are abnormal communications between the cavernous sinus (CS) and dural branches from internal carotid or external carotid arteries. They can often present with ocular symptoms that can mimic a thyroid-associated ophthalmopathy. CS-DAVF are usually successfully treated with an endovascular embolization that can be pursued both through a transvenous or transarterial approach. TAO and CS-DAVF can coexist especially when the ocular symptoms are unilateral. In those cases, an endovascular embolization is usually curative, but sometimes the procedure can fail. Our hypothesis is that some cases of CS-DAVF may be of secondary nature (i.e., caused by compression of the venous outlet by the hypertrophic ocular muscles); therefore, treating the ocular disease with medical therapy may solve the vascular problem as well. We present a case of a CS-DAVF in a patient with TAO successfully treated with sole medical therapy after the failure of a first-line endovascular treatment.

Radiation Exposure During Diagnostic and Therapeutic Angiography of Carotid-cavernous Fistula : A Retrospective Single Center Observational Study

Purpose

The aim of this study was to determine local diagnostic reference levels (DRLs) during endovascular diagnostics and therapy of carotid-cavernous fistulas (CCF).

Methods

In a retrospective study design, DRLs, achievable dose (AD) and mean values were assessed for all patients with CCF undergoing diagnostic angiography (I) or embolization (II). All procedures were performed with the flat-panel angiography system Allura Xper (Philips Healthcare). Interventional procedures were differentiated according to the type of CCF and the type of procedure.

Results

In total, 86 neurointerventional procedures of 48 patients with CCF were executed between February 2010 and July 2021. The following DRLs, AD and mean values could be determined: (I) DRL 215 Gy ∙ cm², AD 169 Gy ∙ cm², mean 165 Gy ∙ cm²; (II) DRL 350 Gy ∙ cm², AD 226 Gy ∙ cm², mean 266 Gy ∙ cm². Dose levels of embolization were significantly higher compared to diagnostic angiography (p < 0.001). No significant dose difference was observed with respect to the type of fistula or the embolization method.

Conclusion

This article reports on diagnostic and therapeutic DRLs in the management of CCF that could serve as a benchmark for the national radiation protection authorities. Differentiation by fistula type or embolization method does not seem to be useful.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas. Institutional Series, Systematic Review and Meta-Analysis

Purpose

Endovascular treatment represents the first-line therapy for cavernous sinus dural arteriovenous fistulas (CS-dAVF); however, different approaches and embolic agents as well as occlusion rates, complications and clinical outcomes are reported among the published series. In this study we performed a comprehensive meta-analysis to investigate clinical and radiological outcomes after endovascular treatment of CS-dAVFs.

Methods

PubMed, Ovid Medline, Ovid EMBASE, Scopus, and Web of Science were screened for a comprehensive literature review from 1990 to 2020 regarding series of patients treated for CS-dAVF with endovascular approaches. We performed a proportion meta-analysis estimating the pooled rates of each outcome also including data of patients treated in our center.

Results

A total of 22 studies reporting 1043 patients and 1066 procedures were included. Chemosis was reported in 559 out of 1043 patients (45.9%), proptosis in 498 (41.5%), and ophthalmoplegia in 344 (23.5%). A transvenous embolization was preferred in 753 cases (63.2%) and coils were used in 712 out of 1066 procedures (57.8%). Overall, 85% (95% confidence interval, CI 69.5–96.1%) of patients had a complete resolution of symptoms, while complications occurred in 7.75% (95% CI 3.82–12.7%) with minimal permanent deficits (0.15%). The mortality rate was 1 out of 1043 patients (< 0.001).

Conclusion

A transvenous coiling is the most common endovascular approach for CS-dAVF, achieving a high percentage of radiological and clinical resolution and low complication rates. Transvenous approaches show less complications than transarterial ones, and coils appear safer than liquid embolic agents.

Dural carotid-cavernous fistulas: our experience with endovascular management

Background

Indirect carotid-cavernous fistulas (CCF) are dural arteriovenous fistula of the cavernous sinus and generally present with ocular symptoms. High index of clinical suspicion and radiological work up is required for diagnosis, and treatment is primarily endovascular embolization. We present our experience in diagnosis and management of indirect CCF along with technical evolution to perform embolization and different vascular accesses for difficult anatomy.

Results

Among a total of 20 indirect CCF cases who were treated with embolization in our department from 2013 to 2020, five (25%) were type C and 15 (75%) were type D. Seven were treated with trans-arterial access only, 11 were treated by transvenous access only, and two were treated by taking both transvenous and trans-arterial access. No recurrence was seen in angiographically cured patients. Out of seven patients who suffered various grades of visual deficit, five recovered completely and two had fixed visual deficit. Third and sixth cranial nerve palsy persisted in two patients even after CCF embolization.

Conclusion

Indirect CCF is a treatable cause of troublesome ocular symptoms. Endovascular embolization is preferred treatment with excellent short- and long-term outcome. The embolization becomes difficult and challenging in cases where the conventional vascular access to the cavernous sinus is occluded.

Use of coronary stent grafts for the treatment of high-flow carotid cavernous fistula

Carotid cavernous fistulas are abnormal communications between the carotid artery or its branches and the cavernous sinus. It can be traumatic or spontaneous. The widely accepted treatment is by detachable balloons. Advancements in the field of endovascular medicine made available other options for the treatment of this condition. Covered stents are widely available and offer preservation of the parent artery while occluding the fistula.

Bilateral carotid cavernous fistula after trauma: a case report and literature review

BACKGROUND

Carotid cavernous fistula is a rare complication that is typically associated with head trauma and skull base fractures. The traumatic bilateral carotid cavernous fistula are significantly rarer.

CASE PRESENTATIONS

We report a case of a 61-year-old man presenting with unilateral exophthalmos, swollen eyelids, conjunctival congestion, and edema etiologically associated with severe trauma. Thereafter, the patient demonstrated symptoms of contralateral oculomotor nerve injury caused by skull base fracture, such as ptosis of eyelid, dilated pupils, and eye movement disorder, and was diagnosed with bilateral carotid cavernous fistula.

CONCLUSIONS

The patient recovered after undergoing endovascular embolization of bilateral cavernous sinus fistulas. The patient demonstrated the classic symptoms of an extremely rare condition known as bilateral carotid cavernous fistula, in only one eye. Reporting and analyzing this case will help us elucidate the underlying mechanisms of this disease.

Middle temporal vein access for transvenous embolization of Cavernous sinus dural arteriovenous fistula: A case report and review of literature

Transvenous endovascular treatment is the first choice for treating most cavernous sinus dural arteriovenous fistulas (CDAVFs). Among several available venous routes, the inferior petrosal sinus is the most commonly used. We report a case of CDAVF treated with endovascular treatment via the middle temporal vein (MTV). A 65-year-old man presented with unilateral chemosis and exophthalmos for approximately two months. Digital subtraction angiography showed a right CDAVF with predominant venous drainage toward the right superior ophthalmic vein. The superior ophthalmic vein primarily drained into the dilated MTV. Both sides of the inferior petrosal sinus were occluded; therefore, transvenous embolization was performed via the MTV route. The fistula was completely obliterated. The patient's symptoms improved and the postoperative course was uneventful. The transfemoral approach via the MTV to treat CDAVF provides a crucial alternative when other venous routes are difficult or impossible to navigate with a catheter.

[Clinical and sonographic examination findings in patients with carotid-cavernous sinus fistulas]

BACKGROUND

Symptoms and clinical findings in patients with carotid-cavernous fistulas are specific. Nevertheless, they can be very mildly expressed. This study aims to point out the potential diagnostic value of ultrasound of the orbit.

METHODS

A total of 25 patients with a reliable angiographic diagnosis of a fistula were reviewed retrospectively. We analyzed the symptoms, clinical findings and demonstrability in ultrasound of the orbit.

RESULTS

The most common clinical findings were nerve palsy, dilation of episcleral vessels and exophthalmos. If an ultrasound had been part of the examination a dilation of the superior ophthalmic vein could be demonstrated in all cases.

CONCLUSION

The expeditious ultrasound investigation provides valuable information for the diagnosis of red eyes which are resistant to treatment. The examiner has to consider a fistula and perform an ultrasound especially when diplopia has newly occurred. Finally, the expedient neuroimaging can be arranged.

Clinical Improvement of Patients with Endovascular Treatment in the Traumatic Carotid-Cavernous Fistula

A carotid-cavernous sinus fistula (CCF) is a clinical condition when there is an abnormal communication between the internal carotid artery, external carotid artery (ECA), or any of their branches to the cavernous sinus. Traumatic CCF (TCCF) is the most common type of all CCFs. This study aims to find clinical improvement of traumatic carotid-cavernous fistulas (TCCF) after endovascular treatment. We predict the degree of clinical recovery in an attempt to make the treatment of TCCF safe and effective. This study reported a series of 28 patients with TCCFs undergoing coiling and ballooning in a period of 3 years, i.e., from December 2014 to December 2017. This is a novel case report about CCF in our country, Indonesia, especially in Surabaya. We performed clinical, angiographical, and radiological assessments before and at regular time periods after the procedure until 6 months. All patients had a partial and complete occlusion of the fistula. Angiographic occlusion of fistula, visualization of the ophthalmic artery, and disappearance of bruit predicted a good clinical outcome. All patients made a recovery at different times, depending on the degree of fistulas and treatment. Improvement in clinical symptoms had a direct correlation with the degree of occlusion. Treatment was divided into coiling and ballooning depending on patient's condition and angiographic examination. Trans femoral cerebral angiography is still very important diagnostic tool in the diagnosis and treatment of TCCFs.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistula via Radial Artery and Median Cubital Vein

Cavernous sinus dural arteriovenous fistula (CS-DAVF) is an arteriovenous shunt where there is fistulous blood flow from the dural arteries from the internal or external carotid artery into the cavernous sinus. The current mainstay of therapy is endovascular treatment. We present a case of restrictive type of CS-DAVF in a 75-year-old male who presented with right eye symptoms. He was treated with embolisation using trans-radial artery access for angiographic runs and a median cubital vein access navigating into the cavernous sinus for coil deployment. This technique completely avoids the conventional technique of a femoral approach and confines all access to the arm. Therefore, there are less risks and complications associated with an arm access, improves patients' comfort and mobility post procedure. Transradial artery and cubital vein access allows for a safe and convenient alternative technique using the arm as compared with conventional transfemoral approach for treatment of CS-DAVF.

A Modified Treatment Through Point-to-Point Coil Embolization for Direct Carotid Cavernous to Fistula: A Single-Center Result

This study aims to assess the safety and efficacy of the modified treatment through point-to-point coil embolization of direct carotid cavernous fistula (dCCF), and evaluate the long-term outcome of patients who underwent the above treatment. A total of 18 patients who suffered from dCCF (a total of 19 fistulas) between January 2013 to May 2020 were analyzed. Among these patients, 14 patients were treated through point-to-point coil embolization of the fistula, while four patients were treated through combined endovascular embolization (coils, a balloon, Onyx, and/or a stent). The number of coils that filled the fistulas was counted. The primary outcome was defined by post-operative digital subtraction angiography (DSA) or the signs after the recanalization of dCCFs during the follow-up period. For patients with dCCF who underwent point-to-point coil embolization, a minimum of three coils and a maximum of 16 coils were used for these 14 fistula patients, and an average of 7.9 coils were used for each fistula, but none of the fistulas was recanalized. Furthermore, two pseudoaneurysms were observed as a result of the compression of the coils. However, none of these 14 patients presented with signs of recanalization of fistulas or cranial paralysis. The procedure applied for the present study was shown to be a safe, economical and efficacious treatment approach for dCCFs through the point-to-point coil embolization of the fistula.