Transvenous embolization of carotid-cavernous sinus fistula associated with a primitive trigeminal artery--case report

A 58-year-old female presented with right conjunctival chemosis and right abducens nerve paresis. Cerebral angiography demonstrated a right carotid-cavernous sinus fistula associated with persistent primitive trigeminal artery. The fistula was treated by introducing detachable coils through the transvenous approach, as the detachable balloon was not available. Follow-up angiography performed 14 days after the embolization revealed complete disappearance of the carotid-cavernous sinus fistula due to thrombosis, which was presumably accelerated by the coils. Transvenous coil embolization should be considered as an alternative treatment for high-flow carotid-cavernous sinus fistula, but only if transarterial balloon embolization is not successful or unavailable.     

Retrospective study on the endovascular embolization for traumatic carotid cavernous fistula

Objective： To retrospectively analyze 95 cases of traumatic carotid cavernous fistula treated by endovascular embolization. Methods： From January 1994 to December 2008, 95 patients with traumatic carotid cavernous fistula were treated in our hospital. All patients received selective cerebral angiography through femoral artery catheterization. Accordingly, 89 cases were treated by detachable balloon embolization, 5 by platinum microcoils and 1 by coveredstem, respectively. Results： In the study, 61 cases achieved successful balloon embolization at the first time. Fifty-six cases had multiple balloons due to the big fistula. Nine cases received balloon embolization twice. But among the 5 patients treated with platinum microcoils, one developed slight brainstem ischemia. After operation the patient had herniparesis and swallow difficulty, but gradually recovered 3 months later. No neurological deficits were observed in other cases. All the cases recovered. Eighty-five cases were followed up for 1-15 years and no recurrence was found. Conclusions： The endovascular embolization for traumatic carotid cavernous fistula is minimally invasive, safe, effective and reliable. The detachable balloon embolization is the first choice in the treatment of TCCF.     

Multimodal endovascular treatment for traumatic carotid- cavernous fistula

bjective：To present our experience in treating traumatic carotid-cavernous fistula （TCCF） by multimodal endovascular treatment.Methods：The management of 28 patients with TCCF between January 2004 and October 2012 in our hospital was retrospectively analyzed.According to imaging charateristics,24 cases were categorized into Type Ⅰ,3 Type Ⅱ and 1 Type Ⅲ.Totally 30 endovascular treatments were performed：Type Ⅰ TCCFs were obliterated via transvenous approach （7/25）,or transarterial approach （18/25） including 6 by detachable balloon occlusion,6 by microcoil embolization,3 by Hyperglide balloon-assisted coil embolization and 3 by a combination of detachable balloon and coil embolization.Two patients were treated with closure of internal carotid artery （ICA）.Type Ⅱ TCCFs were treated with transvenous embolotherapy （2/3） or carotid artery compression therapy （1/3）.The Type Ⅲ patient underwent detachable balloon embolization.Results：Immediate postoperative angiography showed recovery in 26 cases.One recurrent TCCF was found 2 weeks after detachable balloon embolization,and then reobliterated by transarterial coils.Reexamination found balloon deflation and fistula recanalization in 1 patient one month after combination of detachable balloons and coil embolization,which was cured by a second treatment via transvenous approach.The immediate angiography revealed residual blood flow in 4 patients.Among them,2 patients with delayed symptoms at follow-up needed a second treatment,1 patient recovered after carotid artery compression therapy,and the remaining patient＇s symptoms disappeared on digital subtraction angiography at five-month follow-up.CT angiography revealed anterior communicating artery aneurysm in the patient who was treated with closure ofICA 4 years later.Conclusion：According to results of images,characteristics of the fistula and type of drainage,proper treatment approach and embolic material can maximally heal pathological changes,retain the ipsilateral ICA patency and reduce long-term complications.     

Surgical transvenous embolization of a carotid-cavernous dural fistula with cortical drainage via a petrosal vein: two technical case reports

OBJECTIVE AND IMPORTANCE: We present two interesting cases involving carotid-cavernous dural fistulae draining only or predominantly into the petrosal vein after previous incomplete, complicated, endovascular treatments. Transvenous embolization with Guglielmi detachable coils, via the petrosal vein, during surgical exposure completely obliterated the fistulae. CLINICAL PRESENTATION: A 64-year-old man manifesting left ocular symptoms after incomplete embolization of a left carotid-cavernous dural fistula and a 56-year-old woman manifesting left hemiparesis after complicated embolization of a right carotid-cavernous dural fistula were referred to our hospital. A percutaneous transvenous approach was attempted in both cases, but the catheter could not reach the fistula site. A combined open surgical and endovascular approach was then used. INTERVENTION: The hemispheric branch of the petrosal vein was exposed via a retromastoid craniectomy. The catheter was then directly introduced into the hemispheric branch, followed by navigation into the fistula site. The fistula was completely embolized with Guglielmi detachable coils. CONCLUSION: The technique of surgical transvenous embolization via a petrosal vein is a valuable alternative for the treatment of carotid-cavernous dural fistulae that drain only or predominantly into the petrosal vein, when the percutaneous transvenous route is not accessible.     

Navigation-assisted transsphenoidal deflation of a detachable balloon in the cavernous sinus after embolization of a direct carotid-cavernous fistula

Summary We describe a case of transsphenoidal deflation of a detachable balloon after embolization of a carotid-cavernous fistula (CCF). The patient developed complete third and sixth nerve palsies immediately after detachable balloon embolization of the CCF, which was considered to be caused by cavernous sinus (CS) compression by the over-inflated balloon. We performed direct puncture of the balloon via the transsphenoidal route using a frameless neuronavigation system. Navigation-assisted transsphenoidal approach (TSA) is technically feasible for balloon deflation in cases of severe cranial nerve palsies due to an over-inflated balloon.     

A case of non-traumatic direct carotid-cavernous fistula presenting with cerebral infarction

A 76-year-old female presented with a rare case of cerebral infarction as a complication of non-traumatic direct carotid-cavernous fistula (CCF). She had left hemiparesis and magnetic resonance imaging revealed cerebral infarction in the right watershed area. Angiography showed a right high-flow direct CCF with total blood steal. Preoperative 123I-IMP SPECT revealed a hypoperfusion area in the region of the right anterior cerebral artery and right middle cerebral artery. In addition, she had double vision caused by abducens nerve palsy. Transarterial embolization of the fistula with endovascular trapping using detachable coils achieved complete obliteration of the right internal carotid artery and adequate flow reduction of the direct CCF. Postoperative angiography showed good filling of the collateral-flow via the posterior communicating artery without retrograde blood steal to the CCF. Her symptoms improved gradually after the procedure. Diffusion-weighted MR imaging obtained 8 days after the procedure revealed a few high signals in the right hemisphere, suggesting cerebral infarctions, but she presented no symptom. Postoperative 123 I-IMP SPECT showed an improvement of cerebral perfusion in the region of the right MCA posterior and left MCA. Cerebral ischemia caused by direct CCF is rare, and there are only a few reports of non-traumatic direct CCF presenting with cerebral infarction. This very rare case suggests that endovascular trapping is safe and useful as a treatment for direct CCF, especially in the case of an elderly patient with total blood steal.     

可脱性球囊在颅内血管性病变介入栓塞中的应用价值研究

目的总结可脱性球囊栓塞的技术要点,并评价其在当今神经介入治疗中的应用价值。方法对A组36例外伤性颈内动脉海绵窦瘘(TCCF)及B组24例颅内动脉瘤应用可脱性球囊闭塞瘘口或闭塞1侧颈内动脉。结果A组36例中31例闭塞瘘口且保留颈内动脉(ICA)通畅,另5例瘘口及ICA被同时闭塞,ICA通畅率为86.1%,治愈率为100%。B组24例均成功的闭塞了载瘤动脉,其中病情恢复良好者22例;并发脑缺血和脑梗死各2例,其中1例术后死亡,治愈率95.8%。结论可脱性球囊在当今TCCF及某些不可手术夹闭或因故不能行瘤腔内栓塞的颅内动脉瘤患者的介入治疗中仍然具有重要的应用价值。     

外伤性颈内动脉海绵窦瘘的诊断与介入栓塞治疗（附4例报告）

[摘要]目的探讨外伤性颈内动脉海绵窦瘘的诊断和血管内治疗。方法对有头部外伤病史及典型临床表现的患者积极行数字减影血管造影（digitalsubtractionangiography,DSA）检查,有4例确诊后经股动脉入路,用可脱性球囊进行栓塞治疗。3例保持了患侧颈内动脉的通畅,1例行瘘口远近端的颈内动脉闭塞术;3例患者应用1个球囊,1例应用2个球囊。结果4例患者瘘I：1完全闭塞,临床症状缓解,1例于首次术后12h症状再发,再次行栓塞治疗后缓解痊愈。结论DSA检查是诊断颈内动脉海绵窦瘘的金标准;可脱性球囊栓塞治疗是颈内动脉海绵窦瘘的首选治疗方法。     

Endovascular embolization of recurrent traumatic carotid-cavernous fistulas managed previously with detachable balloons

BACKGROUND: This study investigated the causes of recurrent traumatic carotid-cavernous fistulas (RTCCFs) after detachable balloon embolization and evaluated the selection of embolic materials for endovascular treatment of the RTCCFs. METHODS: Over a 10-year period, 116 patients underwent transarterial balloon embolization with occlusion of the fistulas and preservation of the parent arteries. In 15 patients, 18 RTCCFs developed. The causes of RTCCFs included premature balloon deflation and migration (n = 13) or bony fragment puncture of balloons (n = 5). A second or third embolization involved balloons (n = 6), balloons with coils (n = 2), and N-butyl-2-cyanoacrylate with coils (n = 7), or balloon, coils, and N-butyl-2-cyanoacrylate (n = 3). RESULTS: In this study, 17 RTCCFs were successfully occluded after repeat embolization with preservation of parent arteries. One case resulted in recurrent epistaxis. The recurrent fistula and parent artery were occluded with balloons. No significant complications or recurrent fistulas occurred after the last embolization (mean follow-up period, 16 months). CONCLUSIONS: Balloon puncture or premature deflation and migration occasionally cause RTCCFs. Sacrifice of the parent artery rarely is needed. Transarterial embolization remains the best approach, with balloons used first, then coils, N-butyl-2-cyanoacrylate, or both.     

Embolization for traumatic carotid cavernous sinus fistula using platinum coil]

We treated a patient with a traumatic carotid-cavernous fistula (CCF) by embolization using a Tracker catheter and platinum coils by transarterial and transvenous approaches. A 65-year-old female sustained an injury in the right frontal region of the head in April, 1989. After 1 month, she was admitted to our hospital due to exophthalmos, congestion of the palpebral conjunctiva, ptosis, and a bruise in the right frontal region of the head. Right carotid angiography showed a CCF between the anterior ascending segment and the horizontal segment that drains into the superior ophthalmic vein, superior petrosal sinus and inferior petrosal sinus. To occlude the fistula, embolization was performed twice using platinum coils. In the first embolization, the cavernous sinus was approached transarterially and transvenously using a Tracker catheter system, and a total of 7 platinum coils were used for the embolization. The bruise disappeared immediately after embolization but recurred 3 days after the operation. Angiography demonstrated re-communication of the CCF. The second embolization was initially performed using a detachable balloon, but the balloon could not be passed through the fistula. Therefore, a Tracker catheter was advanced to the fistula transarterially and embolization was performed using 3 platinum coils. The fistula was occluded. Follow-up angiography after 1 year in August, 1990 showed complete occlusion of the fistula. The detachable balloon system was recently introduced in neurological and radiological departments, as a new surgical method for CCF. At present, this method is the first choice for CCF. However, the detachable balloon system presents some technical problems.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of spontaneous carotid-cavernous fistulae

Fifteen cases of spontaneous carotid-cavernous fistulae, including 4 patients with spontaneous cure and 8 treated with electrothrombosis, are reviewed. Careful angiographic observation will verify closure of the fistula. Aggravation of visual and/or ocular symptoms can also develop with spontaneous carotid-cavernous fistulae. Recurrence of symptoms and development of collaterals were noted, especially after carotid ligation or embolization of the external carotid artery. Electrothrombosis successfully closed the fistulae in 7 patients. The internal carotid artery was occluded in 1 patient who had a preoperative carotid stenosis at the cervical level. The ability to differentiate angiographically between single and multiple fistulae provides a new possibility that spontaneous carotid-cavernous fistulae can be treated with detachable balloon catheters.     

Treatment of carotid-cavernous sinus fistula by the balloon technique combined with a by-pass procedure using a vein graft-technical note note

A case with spontaneous carotid-cavernous fistula treated by balloon catheter technique combined with a extra-intracranial by-pass using a saphenous vein graft between the common carotid artery and the middle cerebral artery is reported. A 72-year-old female was admitted with complaints of recurrent symptoms of carotid-cavernous fistula 4 months after spontaneous remission. Angiograms showed the presence left internal carotid-cavernous sinus fistula. Poor cross-filling from the right internal carotid artery to the territory of the left internal carotid artery via the hypoplastic right A1 and left posterior communicating artery was also observed. Symptoms such as chemosis, exophthalmos and visual disturbance gradually progressed during the hospitalization. A common carotid-middle cerebral artery anastomosis was performed with a saphenous vein graft and the carotid cavernous fistula was occluded directly with a balloon catheter. The blood flow via the graft, cortical blood flow, cortical tissue O2 and CO2 were continuously measured during the operation. After the internal carotid artery occlusion, sufficient blood flow via the graft and no significant changes of the cortical blood flow, cortical tissue O2 and CO2 were observed. The postoperative angiogram showed that the by-pass was patent and all branches of the left internal carotid artery were filled via the by-pass. The postoperative course was uneventful and the progressive symptoms improved except for visual disturbance on the left. She is in good condition one year after the operation. The usefulness of this surgical procedure with monitoring of cerebral blood flow and metabolism during operation is also discussed.     

Prognostic analysis and complications of traumatic carotid cavernous fistulas after treatment with detachable balloon and／or coil embolization

Objective : To explore the causes of the formation of traumatic carotid-cavernous fistulas and the therapeutic effect of detachable balloon and/or coil embolization and the prevention of its complications. Methods: From October, 1992 to March, 2002, 17 patients with traumatic carotid-cavernons fistulas were treated with detachable balloon and/or coil embolization in our hospital. The clinical data and imaging features of CT, MR and selective angiogram of these patients were analyzed. Results : One week after treatment with embolization, the clinical symptoms of the 17 patients were remitted, and optic cacophony, nystagmns, exophthalmos and dropsy of conjunctiva disappeared. Two patients manifested surgical complications, one patient died. Sixteen patients survived. They were all followed up for more than 2 years, which showed one patient had handicap in movement, and in one patient the signs and symptoms of traumatic carotid-cavernous fistulas reoccurred 2 months after treatment. Conclusions: The detachable balloon and/or coil embolization is safe and reliable. It is a good method to treat traumatic carotid-cavernous fistulas.     

Direct puncture of a prematurely detached balloon in the supraclinoid ICA via the optic canal during embolisation of a traumatic carotid-cavernous fistula

We report a patient with traumatic carotid-cavernous fistula associated with an isolated internal carotid artery in whom, after trans-arterial balloon embolisation, premature balloon detachment occurred with balloon migration to the supraclinoid carotid artery, leading to total occlusion of the blood flow. The carotid flow was eventually restored by direct puncture of the detached balloon via the optic canal and by deploying a coronary stent to fix the balloon in the vascular wall. The fistula was eventually occluded by using detachable coils. He was discharged with a mild hemiparesis and decreased acuity in the left eye.     

Successful transarterial Guglielmi detachable coil embolization of posttraumatic posterior communicating artery-cavernous sinus fistula: technical note

OBJECTIVE: Carotid-cavernous fistulae are uncommon but well-documented sequelae of craniofacial trauma. A rare subset may arise from the posterior communicating artery instead of from the carotid artery proper. The presentation is similar to that of carotid-cavernous fistulae, with ocular pain, chemosis, and proptosis being the common symptoms. The first successful transarterial coil embolization of this type of lesion is described. METHODS: A 42-year-old man presented with severe craniocerebral injury, including multiple craniofacial fractures, after an industrial accident. He required emergent craniotomy for an open depressed cranial fracture and epidural hematoma. Six weeks after presentation, the patient began to exhibit progressive chemosis and proptosis. Magnetic resonance imaging revealed findings consistent with a carotid-cavernous fistula. RESULTS: Angiography revealed a fistula between the posterior communicating artery and the cavernous sinus. The origin of the fistula in the posterior communicating artery was successfully obliterated with Guglielmi detachable coiling. Subsequent studies demonstrated no flow through the fistula and good opacification of the ipsilateral posterior cerebral artery by the vertebrobasilar system. CONCLUSION: Posterior communicating artery-cavernous fistulae are a rare sequel of trauma. They may be treated successfully with the use of transarterial coil embolization.     

Balloon occlusion of a spontaneous fistula of the posterior inferior cerebellar artery. Case report

A case is reported of a large spontaneous right posterior inferior cerebellar artery fistula in which the patient presented with a right cerebellopontine (CP) angle and right cerebellar syndrome. The patient was successfully treated by balloon occlusion at the fistula site. The location of the arteriovenous fistula, the mass effect of its enlarged draining veins on the cerebellum and CP angle structures, and the simple therapeutic endovascular occlusion with a detachable balloon make this case unique.     

A case of posterior cerebral artery aneurysm associated with idiopathic bilateral internal carotid artery occlusion: case report

BACKGROUND: Aneurysms of the posterior circulation are challenging lesions to neurosurgeons, despite improvements in microsurgical techniques and advances in skull base approaches. We present a rare case of a posterior cerebral artery (PCA)-posterior communicating artery (PcomA) junction aneurysm associated with bilateral internal carotid artery (ICA) occlusion successfully treated with an endovascular procedure. CASE DESCRIPTION: A 57-year-old female presented with sudden onset of severe headache and loss of consciousness. CT scan showed diffuse subarachnoid hemorrhage and acute hydrocephalus. The patient developed severe neurogenic pulmonary edema and shock. Although her neurogenic pulmonary edema did not resolve, she recovered from shock. However, her general condition was so critical and her vital signs so unstable, that direct surgery under general anesthesia was considered too risky. A cerebral angiogram showed complete occlusion of both internal carotid arteries without any Moyamoya vessels. A saccular aneurysm located at the right PCA-PcomA junction was seen. To obliterate the aneurysm and prevent rerupture, the patient underwent coil embolization via an endovascular approach under sedation with local anesthesia. The balloon remodeling technique was useful to prevent occlusion of parent arteries. Finally, four interlocking detachable coils (IDC) with a total length of 44 cm were used to completely obliterate the aneurysm using the balloon remodeling technique. The patient made a full recovery after treatment and the aneurysm remained obliterated 2 years after coil embolization. CONCLUSIONS: We emphasize the advantages of the endovascular approach for the patient in critical condition. We believe that this is the first report of a PCA-Pcom junction aneurysm associated with bilateral ICA occlusion without moyamoya disease.     

Traumatic carotid-cavernous fistula identified by three-dimensional digital subtraction angiography--technical note

Conventional digital subtraction angiography (DSA) identified a right carotid-cavernous fistula (CCF). Three-dimensional DSA (3D-DSA) was used to evaluate the CCF before treatment. The 3D-DSA images showed the anatomical relationship of the parent artery and the veins, which was difficult to understand on conventional DSA. The endoscopic image revealed the fistula and cavernous sinus. The direction and location of the fistula could be confirmed. However, the size of the fistula significantly varied depending on the adjustment of the window thresholds, so the balloon size could not be selected based on the images. Catheterization and subsequent embolization of the cavernous sinus with a detachable balloon via the femoral artery was successfully accomplished by referring to the 3D-DSA images.     

Pterional keyhole approach to middle cerebral artery aneurysms through an outer canthal skin incision.

OBJECT: The supraorbital keyhole approach via an eyebrow skin incision provides a method for the minimally invasive clipping of aneurysms located in the circle of Willis, but has disadvantages for aneurysms located in the lateral Sylvian fissure. The pterional keyhole minicraniotomy via an outer canthal skin incision is proposed for the clipping of unruptured aneurysms of the middle cerebral artery (MCA). METHODS: The procedure consists of a 35-mm outer canthal skin incision, partial temporal muscle dissection restricted in the pterion, a 20-25-mm keyhole minicraniotomy, and a 15-20-mm dural incision to expose the lateral Sylvian fissure. Twenty keyhole clipping procedures were performed in 20 patients with unruptured MCA aneurysms. RESULTS: Only one patient showed a temporary mild hemiparesis (reversible ischemic neurological deficit) due to lacunar infarction. No shaving of scalp hair, drain placement, or anticonvulsant drug administration were required. Most patients were discharged on the 2nd or 3rd postoperative day. One patient showed a weakness of the frontalis muscle, but this complication was eliminated by the definition of a safety zone to avoid damage to the frontal branch of the facial nerve. CONCLUSIONS: The pterional keyhole approach via outer an canthal skin incision is another treatment option for relatively small, unruptured MCA aneurysms.     

Clip occlusion versus coil embolization for the treatment of cerebral aneurysms

Advances in the endovascular treatment of intracranial aneurysms since the advent of detachable coil embolization continue to expand the spectrum of lesions amenable to minimally invasive therapy. The feasibility of treating a given cerebral aneurysm by a given open or endovascular modality does not necessarily make such an approach the optimal choice. Rather, any given cerebral aneurysm and patient should be carefully analyzed on a multitude of parameters which are based on available adjunctive technology, aneurysm morphology and characteristics, endovascular vs. microsurgical accessibility, and long-term angiographic outcome. In addition to patient age, co-morbid conditions, lesion size and attendant risk, one must also consider patient preference with respect to length of hospital stay, recovery duration and required follow-up and radiographic assessments. The relentless improvements in minimally invasive embolization therapies ranging from coiling with adjunctive balloon and stent support to the emerging role of flow-diversion must be balanced against the lower cost and complexity associated with longitudinal clinical and radiographic follow-up requirements of microsurgical clipping. This review will consider the various factors involved in the determination of optimal modality choice based on an assessment of clinical, morphological and anatomical considerations. In this rapidly evolving field, the quest for maximizing protection from aneurysm rupture at the lowest neurological cost dictates that a balance be maintained between technical virtuosity and procedural safety of either microsurgical clipping or endovascular repair to insure that the advantages of the selected modality not be negated by its associated shortcomings.