Carotid-cavernous fistula: current concepts in aetiology, investigation, and management

A carotid-cavernous fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus and may be classified as either direct or dural. Direct CCFs are characterized by a direct connection between the internal carotid artery (ICA) and the cavernous sinus, whereas dural CCFs result from an indirect connection involving cavernous arterial branches and the cavernous sinus. Direct CCFs frequently are traumatic in origin and also may be caused by rupture of an ICA aneurysm within the cavernous sinus, Ehlers-Danlos syndrome type IV, or iatrogenic intervention. Causes of dural CCFs include hypertension, fibromuscular dysplasia, Ehlers-Danlos type IV, and dissection of the ICA. Evaluation of a suspected CCF often involves non-invasive imaging techniques, including standard tonometry, pneumotonometry, ultrasound, computed tomographic scanning and angiography, and/or magnetic resonance imaging and angiography, but the gold standard for classification and diagnosis remains digital subtraction angiography. When a direct CCF is confirmed, first-line treatment is endovascular intervention, which may be accomplished using detachable balloons, coils, liquid embolic agents, or a combination of these tools. As dural CCFs often resolve spontaneously, low-risk cases may be managed conservatively. When invasive treatment is warranted, endovascular intervention or stereotactic radiosurgery may be performed. Modern endovascular techniques offer the ability to successfully treat CCFs with a low morbidity and virtually no mortality.

Bilateral carotid-cavernous fistula with spontaneous resolution: A case report and literature review

RATIONALE

Bilateral carotid-cavernous fistula (CCF) is rare and serious extra-ocular disease occurring in clinical which may result in severe complication. Unique manifestations and imaging examinations are important to the diagnosis.

PATIENT CONCERNS

A case of bilateral carotid-cavernous fistula in an 60-year-old healthy man caused by a head injury is reported. Further clinical symptoms and signs and imaging examinations lead to the correct diagnosis.

DIAGNOSES

Computed tomography angiography of the brain aroused suspicion of bilateral CCF. On physical examination, intraocular pressure in the right eye was 35 mm Hg, while the other eye was 56 mm Hg.

INTERVENTIONS

After diagnosis, the patient chose conservative treatment for some reasons.

OUTCOMES

The symptom of him had relieved in both eyes but no light perception in the right eye after two months telephone follow-up.

LESSONS

Our case study demonstrated that a highly suspicion must be maintained when managing such patients to prevent serious consequences. At the same time, the early diagnosis and treatment of the disease have a critical relationship to the prognosis of patients, which should be paid attention to.

Common carotid pseudoaneurysm after carotid endarterectomy: a case presentation

A patient with a previous history of neck cancer and carotid endarterectomy presents with a pulsatile cervical mass. Further evaluation reveals the presence of a pseudoaneurysm of the common carotid artery. The endovascular treatment options and techniques employed to exclude the pseudoaneurysm are presented and discussed.

[Neuro-ophthalmology and interventional neuro-radiology--co-treatment for carotid cavernous sinus fistula]

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous communications in the cavernous sinus. In many cases of CCF's the primary signs are ocular manifestations, which include: pulsatile proptosis, orbital bruit, chemosis and conjunctival injection, elevated intraocular pressure, venous stasis retinopathy, and cranial nerve pareses. Patients in whom the fistula causes arterial drainage into the cerebral veins and sinuses are at risk for intracranial hemorrhage. The most common treatment for CCF's is endovascular occlusion of the lesion. The goal of this procedure is to occlude the fistula but preserve the patency of the internal carotid artery. The CCF itself, as well as its treatment, can be sight- and even life-threatening. We describe 3 case reports of patients with CCF, in order to demonstrate the cooperation between the neuro-opthalmologist and the invasive neuro-radiologist, in the follow-up of the patient and in the treatment timing decision.

Diffusion restriction in thrombosed superior ophthalmic veins: two cases of diverse etiology and literature review

Thrombosis of superior ophthalmic veins (SOV) is a well known entity occurring secondary to varied etiologies. We describe diffusion restriction in thrombosed SOV in two cases of different etiologies- bilateral involvement in a patient with septic cavernous sinus thrombosis (CST) and another where embolisation of an indirect carotico-cavernous fistula (CCF) resulted in complete SOV thrombosis accompanied by clinical worsening. Our cases add to the limited literature on diffusion findings in SOV thrombosis.

Transarterial coil embolization of a carotid-cavernous fistula which occurred during stent angioplasty

Intracranial endovascular procedures are less invasive and relatively safe; however, these procedures do carry a risk of complications, such as thromboembolization, arterial injury, and vessel occlusion. We present a case of carotid-cavernous fistula development secondary to injury of the cavernous segment of the internal carotid artery (ICA) during stent angioplasty and its treatment by transarterial coil embolization. Probable causes of this complication and its treatment method are discussed. To the best of our knowledge, this is the first report of such a case.

Trans-arterial embolisation therapy of dural carotid-cavernous fistulae using low concentration n-butyl-cyanoacrylate

BACKGROUND

Trans-venous embolisation has been accepted as the preferred treatment for dural carotid-cavernous fistulae (DCCF). However, such an approach is not always feasible. In this circumstance, trans-arterial embolisation with low concentration n-butyl-cyanoacrylate glue (NBCA) may be a feasible alternative. We report our results and experience of this method for DCCF.

MATERIALS AND METHODS

Five patients with DCCF were treated by trans-arterial embolisation using low concentration NBCA by wedging the microcatheter into the main feeding artery. All five lesions were associated with venous drainage into the superior ophthalmic vein. The inferior petrosal sinus was patent in one patient and thrombosed in four. Additional venous drainage into the Sylvian vein and the superior petrosal sinus was observed in two patients.

FINDINGS

The definitive NBCA injection was performed via the branches of the middle meningeal artery in three patients and accessory meningeal artery as well as ascending pharyngeal artery in two patients. Four patients showed complete obliteration of the DCCF on the post-embolisation angiogram, and follow-up studies showed clinical cure or improvement and successful obliteration of the DCCF. One patient had a residual DCCF after the procedure, but showed complete obliteration and clinical cure at 5-month follow-up. Glue penetrated into the Sylvian vein in one patient during the procedure without sequelae. Two patients had transient worsening of ocular symptoms after the procedure.

CONCLUSIONS

Trans-arterial embolisation with low concentration NBCA using a wedged microcatheter technique is still a safe and effective treatment for DCCF when the transvenous approach is not feasible. However, care must be taken to prevent inadvertent arterial and venous embolisation.

Carotid cavernous fistula in CNS choriocarcinoma

Carotid artery-cavernous sinus fistulas (CCFs) are infrequently reported in the pediatric population, and are rarely reported in conjunction with CNS neoplasms. The authors present a 7-year-old girl with CNS choriocarcinoma who acutely developed left eye proptosis and conjunctival injection. Computed tomography angiography revealed a CCF, which was endovascularly embolized with detachable coils. There may be a direct cause-and-effect relationship between choriocarcinoma and development of CCFs.

Endovascular Stent Placement of Cervical Internal Carotid Artery Dissection Related to a Seat-Belt Injury: A Case Report

OBJECT

The incidence of carotid artery dissection related to blunt injury is very low, but the mortality rate is high. Rapid diagnosis and proper treatments are discussed.

CLINICAL PRESENTATION

A 48-year-old woman presented diplopia and pulsating tinnitus of the left ear. An angiography showed a carotid cavernous fistula (CCF) and dissection of the extra-cranial internal carotid artery (ICA). To treat the dissection, a self-expanding endovascular stent was used. She has been followed for 6 years without any event and the ICA is patent.

CONCLUSION

Prompt diagnosis without delay and intimate follow-up is the key for the treatment of a carotid injury. Those patients who exhibit cervical bruits and/or seat-belt signs should be examined aggressively. Angioplasty with stents is amenable for patients with traumatic carotid dissections requiring vascular reconstruction in the acute stage.

Carotid artery pseudoaneurysm resulting from an injury to the neck by a fouled baseball

OBJECTIVE

Blunt carotid artery injury resulting in either dissection or pseudoaneurysm is a rare entity that can result in significant morbidity and mortality if undiagnosed. Although unavoidable in certain traumatic situations such as motor vehicle collisions, direct neck trauma in sports may be preventable with the use of proper protective equipment.

CLINICAL PRESENTATION

The following report documents a case of extracranial carotid artery dissection resulting from a foul ball striking the upper, lateral neck of an umpire. The patient had transient right upper extremity monoparesis. He later presented with right hemiparesis and aphasia that resolved over several hours. Imaging studies demonstrated a left carotid pseudoaneurysm with evidence of left hemispheric embolic infarcts.

INTERVENTION

Systemic intravenous anticoagulation with heparin followed by oral anticoagulation with warfarin for 6 months, subsequently followed by aspirin monotherapy.

CONCLUSION

The use of standard protective equipment did not adequately cover the patient's neck in the region of the cervical carotid artery. This case illustrates that modification in current catcher and umpire equipment could potentially avoid this rare but significant vascular injury.

Diagnosis and treatment of dural carotid-cavernous fistulas: a consecutive series of 27 patients

OBJECTIVES

To report clinical characteristics, angiographical findings and results of endovascular treatment of patients presenting with dural carotid-cavernous fistulas (DCCFs).

METHOD

Retrospective analysis of 27 consecutive patients with DCCF referred to a specialised interventional neuroradiology department.

RESULTS

Orbital and neuro-ophthalmological symptoms were the most common clinical presentation at diagnosis (n = 25). The venous drainage of the fistula involved the ipsilateral superior ophthalmic vein in 24 patients, the contralateral cavernous sinus in 6 and a leptomeningeal vein in 5 patients. Thrombosis of at least one petrosal sinus was found in 23 patients. 7 patients did not receive endovascular treatment: 3 had spontaneous DCCF obliteration, and 4 had only minor clinical symptoms and no leptomeningeal venous drainage on an angiogram. 20 patients received endovascular treatment via either a transvenous (n = 16) or a transarterial approach (n = 4). Complete occlusion of the fistula was obtained in 14 of 16 (87%) patients treated by the transvenous approach and in 1 of 4 (25%) patients treated by the transarterial approach. 16 patients had early clinical improvement after endovascular treatment. One patient had a cerebral haemorrhage after transvenous embolisation of a DCCF with leptomeningeal drainage. On follow-up, all patients treated by the transarterial route remained symptomatic, whereas 10 of 14 (71%) patients cured by the transvenous route were asymptomatic.

CONCLUSIONS

Transvenous embolisation is a safe and efficient endovascular approach to treat patients with DCCF. However, this technique requires a long learning curve.

Minimally Invasive Keyhole Approach for Removal of a Migratory Balloon Complicated by Endovascular Embolization of a Carotid-Cavernous Fistula

PURPOSE

This report presents our experience in using a minimally invasive keyhole approach to remove a migratory balloon in the cerebral artery in one patient.

CASE REPORT

A 19-year-old male suffered from carotid-cavernous fistula after craniofacial trauma two months previously. The patient received endovascular embolization of a carotid-cavernous fistula with detachable balloons. Unfortunately, migration of one balloon to the right middle cerebral artery (MCA) at the M1-M2 junction was noted after detaching the balloon during this procedure. Volume expansion, anticoagulation therapy and an emergency pterional keyhole approach with removal of the displaced balloon were performed successfully. Transient left hemiparesis due to temporary occlusion of the right middle cerebral artery by the balloon was promptly alleviated. There was no definite neurological sequel after the operation.

CONCLUSIONS

Although detachable balloon embolization is the best initial treatment of direct carotid-cavernous fistulas, it is likely to migrate to downstream cerebral arteries. We recommend a minimally invasive pterional keyhole approach as a good alternative for treating such endovascular complications to improve outcome.

[Venous infarction associated with carotid-cavernous fistula]

We report an 88-year-old woman who developed a hemorrhagic venous infarction in the left cerebral hemisphere and brainstem, in association with left carotid-cavernous fistula (CCF). Without aura the patient noticed diplopia due to left abducens palsy, and exophthal mos and congestion of the left eye. Brain CT revealed extrusion of the left eye, and dilatation of left superior orbital vein and cerebral cortical veins. She received diagnosis of CCF. Brain CT also revealed a small mass in the left ethmoidal sinus, which was not attached to the CCF. Biopsy of the mass was done under local anesthesia. On the following she had high fever. Her consciousness level deteriorated and she developed right hemiparesis FLAIR images of MRI showed, extensive high signal lesions in the left frontal and temporal cortices, basal ganglia, thalamus, midbrain and pons. These findings were consisted with venous infarction, possibly associated with peri-operative infection and hypovolemia. Intracranial hemorrhage occur in 3% of cases with CCF, but venous infarction was much rarer. The patients with CCF, who show dilatation of cortical veins in CT or MRI, have a higher risk of cerebral hemorrhage or infarction, and should be carefully observed.

Intracranial dural arteriovenous and carotid-cavernous fistulae and paragangliomas

This chapter summarizes the diagnostic criteria and reliability of ultrasound detection of intracranial dural arteriovenous fistulae (DAVF), carotid-cavernous fistulae (CCF), and paragangliomas. In arteries feeding DAVF ultrasound shows increased blood flow, systolic and, especially, end-diastolic velocities causing a decreased resistance index (RI), and an increased diameter. The RI of the external carotid artery (ECA; cutoff: right, 0.72; left, 0.71) yielded a sensitivity of 74%, a specificity of 89%, a positive predictive value of 79%, and a negative predictive value of 86%, for detecting DAVF. Preliminary data suggest that contrastenhanced transtemporal color duplex sonography (CDS) may be useful for screening patients with clinical suspicion of DAVF of the transverse/sigmoid sinus. Most patients with CCF show a dilated superior ophthalmic vein with reversed blood flow direction. Decreased RI and increased blood flow and flow velocities are found in internal carotid arteries supplying the cavernous sinus directly through a fistula (type A CCF) at extracranial CDS, and sometimes in the cavernous sinus of CCF at transtemporal CDS. Definite diagnosis of DAVF and CCF is performed with catheter angiography. Typical CDS findings observed in paragangliomas of the head and neck include their solid, well-defined, and hypoechoic appearance, hypervascularity, intratumoral flow direction, displacement of the internal carotid artery (ICA) and ECA as well as the internal jugular vein. Whereas carotid body tumors can be visualized completely in most patients, other paragangliomas, for example, of the vagal nerve, are at best partially depicted due to their location in the upper neck. Confirmation of ultrasound suspicion of paraganglioma by magnetic resonance imaging or computed tomography of the neck is mandatory.

IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection

The authors reviewed the histories of 33 patients (ages 44 to 50 years) treated with IV thrombolysis for acute stroke due to spontaneous cervical carotid artery dissection. Median NIH Stroke Scale (NIHSS) score on admission was 15. No new or worsened local signs, subarachnoid hemorrhage, pseudoaneurysm formation, or rupture of the cervical ICA were observed. At 3 months, median NIHSS was 7 and median modified Rankin Scale (mRS) 2.5; mRS < or = 2 was observed in 17 patients.

Spontaneous intracerebral hematoma from transient occult carotid-cavernous fistula: a case report

After the spontaneous relief of initial symptoms by traumatic carotid-cavernous fistula (CCF), paradoxical worsening of patient's condition can be followed. We present a case of a 60-yr-old man whose audible bruit from a traumatic CCF had completely disappeared. A few days later, however, the patient had spontaneous intracerebral hematoma with cortical venous drainage. Complete obliteration of the fistula was achieved after embolization. When initial audible bruit in traumatic CCF disappears suddenly, cerebral angiography should be performed to differentiate venous hypertension by the hemodynamic changes of the cavernous sinus channels from spontaneous resolution of CCF.

Necrotic nasopharyngeal mucosa: an ominous MR sign of a carotid artery pseudoaneurysm

Massive hemoptysis is not commonly seen in patients who have nasopharyngeal carcinoma. It most often is the result of both radiation therapy and skull base infection. We present a practical imaging approach by using MR imaging and conventional angiography that may facilitate the prevention of such life-threatening bleeding and help provide effective control of infection. With the aid of these studies, clinicians may be able to manage this condition with more confidence.

Utility of source images of three-dimensional time-of-flight magnetic resonance angiography in the diagnosis of indirect carotid-cavernous sinus fistulas

BACKGROUND

We sought to assess the relative contribution of magnetic resonance imaging (MRI), maximum intensity projection (MIP), and source images of three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) to the diagnosis of indirect (dural) carotid-cavernous sinus fistulas (CCFs).

METHODS

MRI and 3D TOF MRA were obtained in eight consecutive patients with indirect CCFs confirmed by conventional catheter angiography. Two radiologists masked to the angiographic results reviewed images retrospectively to evaluate the efficacy of MRI and 3D TOF MRA source and MIP images in the diagnosis of CCF.

RESULTS

MRI disclosed CCF in five of eight cases; MIP images of TOF MRA disclosed CCF in four cases; source images of TOF MRA disclosed all eight CCF cases.

CONCLUSIONS

The MRA source images are indispensable for a confirmatory diagnosis of indirect (dural) CCF. Underdiagnosis may occur by relying on MRI or 3D TOF MIP images alone.

Embolization of indirect carotid-cavernous sinus fistulas using the superior ophthalmic vein approach

OBJECTIVES

In indirect carotid-cavernous sinus fistulas (CCF), abnormal connections exist between tiny dural branches of the external and/or internal carotid system and the cavernous sinus. Usually this kind of fistula occurs spontaneously and is characterized by a low shunt volume. Alternative vascular approaches for embolization are required when standard interventional neuroradiological access via arterial or transfemoral venous routes is not feasible.

PATIENTS AND METHODS

Two symptomatic patients with indirect CCFs are described. Transarterial and transfemoral venous approach was unsuccessful or resulted in incomplete occlusion of the CCF. Therefore, the superior ophthalmic vein (SOV) was surgically exposed and retrograde catheterized to allow the delivery of platinum coils to the fistula point via a microcatheter.

RESULTS

Complete fistula obliteration was accompanied by recovery of the clinical symptoms.

CONCLUSION

The surgical SOV approach might be sufficient when standard neuroradiological procedures do not succeed. The technique is safe and effective when performed by an interdisciplinary team.

Endovascular management of carotid-cavernous fistula combined with ipsilateral internal carotid artery occlusion due to gunshot: contra-lateral arterial approach

We hereby report the endovascular management of a posttraumatic caroticocavernous fistula combined with an occlusive ipsilateral carotid dissection; this was successfully managed by a contra-lateral arterial approach via the anterior communicating artery.

Carotid cavernous fistula in a patient with Graves' ophthalmopathy

The clinical manifestations of carotid cavernous fistula, an abnormal arteriovenous connection between the cavernous sinus and the carotid artery, can closely mimic the cardinal signs of Graves' ophthalmopathy, an inflammatory disorder of the orbit usually associated with autoimmune thyroid disease. Therefore, carotid cavernous fistulas are generally considered in the differential diagnosis of Graves' ophthalmopathy, especially when the eye involvement is unilateral or asymmetric, and there is the need for exclusion of rarer etiologies of orbital disease. This is the first report of the simultaneous occurrence of Graves' ophthalmopathy and carotid cavernous fistula. The patient was a 67-yr-old woman who presented with a history of Graves' disease with mild bilateral ophthalmopathy treated with radioiodine following a 10-yr therapy with methimazole; after radioiodine treatment, ophthalmopathy deteriorated. At the time of our initial clinical evaluation the ocular involvement of the patient was symmetric, and no evidence of any associated condition was found. However, the response of eye disease to corticosteroid treatment was markedly unequal, resulting in evident asymmetry. This prompted a reconsideration of the diagnosis and a new evaluation of the patient with sensitive techniques, leading to the further diagnosis of carotid cavernous fistula.

Brainstem congestion caused by direct carotid-cavernous fistula--case report

A 41-year-old woman presented with tinnitus in the left ear and headache, followed by diplopia and pain in the left cheek. Angiography showed a left high-flow direct carotid-cavernous fistula (CCF), causing steal of the blood flow from the internal carotid artery into the cavernous sinus. A few days later, she rapidly developed right hemiparesis, dysarthria, and ocular conjugate deviation to the right, and became somnolent. Angiography at that time revealed occlusion of the superior petrosal sinus, causing engorgement of the veins in the surrounding brainstem. The CCF was completely embolized with interlocking detachable coils. Her consciousness disturbance and ophthalmoparesis dramatically improved within a few days, and the right hemiparesis and dysarthria gradually resolved. Magnetic resonance (MR) imaging after the treatment showed small pontine hemorrhage and perifocal edema but no ischemic lesions in the cerebral hemisphere. Re-evaluation of the MR imaging with gadolinium taken on admission demonstrated engorged veins in the brainstem parenchyma, which corresponded to the hemorrhagic lesion in the brainstem. Brainstem congestion caused by direct CCF is very rare, but it can be life-threatening. Good outcome can be expected if the CCF is completely occluded before congestive hemorrhage occurs.

False aneurysm of cavernous carotid artery and carotid cavernous fistula: complications following transsphenoidal surgery

We present two cases of carotid injury during transsphenoidal surgery for pituitary adenoma. While in one of the cases it resulted in the formation of a false aneurysm of cavernous carotid artery, in the other patient, a carotid cavernous fistula (CCF) formed. The false aneurysm was managed by surgical trapping and the patient had an uneventful recovery. The CCF was initially managed with balloon embolization. The balloon got deflated and resulted in a false aneurysm with persistent CCF. This was occluded with Guglielmi Detachable Coils (GDC). The management options are discussed and relevant literature is reviewed. We emphasize the importance of an early cerebral angiography to know the status of the injured carotid artery and formation of false aneurysm / fistula.

Indirect carotid cavernous fistula appeared after balloon embolization of direct CCF

The authors describe a case of indirect carotid cavernous fistula (CCF) appearing five months after embolization for traumatic direct CCF, which was treated six months after the trauma. Long-term (six months) venous hypertension to the affected cavernous sinus due to direct CCF and cavernous sinus thrombosis following a balloon embolization were considered as an etiology of the de novo dural arteriovenous fistula. The recurrent symptoms of CCF are usually related to detached balloon disorder, but delayed recurrence may be caused by the de novo dural AVF, if the direct CCF was treated in the chronic state.

Value of transcranial Doppler ultrasonography in the diagnosis and follow-up of carotid-cavernous fistulae

The introduction of transcranial Doppler ultrasonography (TCD) has made it possible to examine blood flow characteristics in carotid-cavernous sinus fistulae (CCSF) in a noninvasive, relatively simple, and reliable way. This study investigated the usefulness of TCD in the diagnosis and follow-up of various CCSF subtypes. We found characteristic TCD findings associated with high-flow CCSF, but perhaps more importantly, found this technique to be an excellent tool also for detecting and following treatment results in low-flow CCSF. The low-flow fistulae exhibit less specific clinical signs and are harder to distinguish using the noninvasive radiological methods of computed tomography (CT) and magnetic resonance imaging (MRI). The impact of our findings on future approaches to the diagnosis and follow-up of these different types of acquired vascular shunts is also discussed. The conclusions were as follows: a) TCD parameters (blood flow velocity and pulsatility index) for CCSF are specific, and are thus valuable in the hemodynamic assessment of these lesions. b) Since dural CCSF feature more subtle hemodynamic changes and CT and MRI findings may be normal, these cases pose diagnostic challenges. In these situations, TCD reveals specific diagnostic findings and allows the examiner to determine whether cerebral angiography is indicated.

The Ishikawa classification of cavernous sinus lesions by clinico-anatomical findings

PURPOSE

The Jefferson classification has been used to localize cavernous sinus lesions. However, this classification occasionally showed dissociation between identified localization and clinical findings. We investigated the clinical applicability of the newly proposed Ishikawa classification based on serial topographic sections of human cavernous sinus and the clinical findings.

METHODS

In the Ishikawa classification, the cavernous sinus is divided into three portions, that is, anterior, middle, and posterior, demarcated by the location of the intracranial orifice of the optic canal and the entry of the maxillary nerve into the cavernous sinus. A total of 162 patients with cavernous sinus lesions were classified using both the Jefferson and the Ishikawa classifications and the clinical applicability of these two classifications was studied. Characteristics of the localization of lesions were also examined in each etiological type.

RESULTS

By the Jefferson classification, 11% of the 162 patients had the anterior type of lesion, 12% the middle, 8% the posterior type, and 69% the unclassifiable type. However, by the Ishikawa classification, 35% had the anterior type, 10% the middle type, 22% the posterior type, 5% the whole type, and 28% the unclassifiable type of lesion. Furthermore, the Ishikawa classification revealed that the etiology of the anterior type was mainly inflammation, and that the etiology of the posterior and whole types was tumors.

CONCLUSION

The Ishikawa classification is clinically useful to identify and classify the localization of cavernous sinus lesions.

Carotid-cavernous fistula with brainstem congestion mimicking tumor on MRI

Article abstract-A 65-year-old woman presented with a left abduction deficit and "red eye," mild proptosis, chemosis, arterialization of the conjunctival vessels, intention tremor, and bilateral pyramidal signs. MRI showed significant left-sided brainstem involvement that mimicked a tumor. Right hemiplegia ensued 1 week later. Venous congestion of the brainstem with hemiplegia resulting from shunting of blood flow from both carotid arteries is an extremely rare complication of carotid-cavernous fistula.

Direct caroticocavernous fistula and traumatic dissection of the ipsilateral internal carotid artery: endovascular treatment

After severe craniocerebral trauma a 14-year-old boy developed progressive exophthalmos with venous congestion and chemosis, due to a direct caroticocavernous fistula. Angiography revealed traumatic occlusion of the ipsilateral internal carotid artery and absence of the inferior petrosal sinus. After failure of an approach via the anterior and posterior communicating arteries, the cavernous sinus was successfully catheterised through the occluded internal carotid artery, and embolisation performed with coils.

[Refractory carotid-cavernous fistula: causes and countermeasures]

OBJECTIVE

To explore the causes and countermeasures of refractory carotid-cavernous fistula (CCF).

METHODS

Twelve refractory cases from 123 cases of consecutive traumatic CCF during 12 years were reviewed.

RESULTS

The main causes of refractory CCF were: small or large fistula's opening, or constrictive parent artery; inappropriate early treatments such as ligature of internal carotid artery or common carotid artery, balloon detachment of, and non-dense packing of coils inside the cavernous sinus; unexpected deflation or balloon displacement of resulting in fistula recurrence. Anatomical cure was achieved in 11 cases, and clinical care in 1 by using balloon or/and coil or/and NBCA (n-butal 2-cyanoacrylate) through arterial, venous or surgical approach.

CONCLUSIONS

refractory CCF can be treated effectively skilled catheterization and embolization as well as appropriate approach and embolic material according to fistula structure and vascular route.