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. Received: 21 July 1998/Accepted: 5 April 1999     

Spontaneous resolution of symptoms in an infant with a congenital dural caroticocavernous fistula

We report a 5-week-old boy with a congenital dural caroticocavernous fistula (CCF). He had gradually progressive proptosis, dilated conjunctival veins, chemosis, abducens nerve palsy and an objective bruit. Angiography of the right common carotid artery revealed fistulous communication in the cavernous sinus (CS) region. The CS was fed by the middle meningeal artery and drained through the superior ophthalmic vein and the superior petrosal vein. The child's symptoms and signs disappeared within a few weeks and did not recur over 11 months. At that time, however, angiography still showed a small communication between the right external carotid artery and the CS.     

Coil embolization of cavernous sinus in patients with direct and dural arteriovenous fistula

To determine technical success and acute complication rates after endovascular coil packing of the cavernous sinus. Nineteen patients presented with either direct (13) or dural (6) arteriovenous fistula (AVF) and were treated by means of coil embolization of the cavernous sinus. The aim of treatment was complete obliteration of the fistula. In a retrospective study, the degree of obliteration, regression of symptoms as well as complication rates were evaluated. Initial complete obliteration was achieved in 12 patients, subtotal occlusion of the sinus in 6 and incomplete packing with major residual fistula in 1 of the patients. Retreatment was successfully performed in two patients with early recurrence of AVF. Follow-up showed complete occlusion rates in 16 and subtotal obliteration in 3 patients. Chemosis and exophthalmus regressed rapidly in all affected patients. Persistence of cranial nerve deficits was observed in 11 cases. Postinterventional thrombosis of the ophthalmic vein was the only major acute complication (n = 2). Coil embolization of the cavernous sinus in cases with AVF is a complex procedure that is technically feasible and safe in the majority of cases. Adequate anticoagulation is recommended to avoid thrombembolic complications. Long-term outcome has to be determined by further studies.     

以突眼为表现的眼部血管病——颈动脉海绵窦瘘的介入治疗

目的探讨颈动脉海绵窦瘘眼部表现特点、影像学检查及介入治疗方法。 方法回顾分析5年中18例首诊于我院眼科的颈动脉海绵窦瘘者的眼部症状及体征、影像学检查、治疗方法等。18例患者均行介入手术治疗,其中应用可解脱球囊封堵瘘口12例,应用弹簧圈+Onyx胶封堵瘘口3例,覆膜支架隔绝瘘口3例。 结果所有病例中最常见的眼部表现为搏动性眼球突出、球结膜充血水肿、眼球运动障碍等。头颅或眼部CT平扫检查所有病例均显示患侧眼球突出,眼上静脉增粗;全部患者均行数字减影血管造影检查明确诊断。本组18例（20眼）均行介入手术治疗,其中应用可解脱球囊封堵瘘口12例（14眼）,结果10例（12眼）瘘口完全闭塞,发生并发症2例,无严重并发症或死亡病例。应用弹簧圈+Onyx胶封堵瘘口3例（3眼）、覆膜支架隔绝瘘口3例（3眼）,瘘口均完全闭塞,无并发症或死亡病例。全部手术患者眼部症状和体征均得到明显改善。随访时间（12±3.4）个月,无复发病例,颈动脉覆膜支架内未发生狭窄及闭塞。 结论对于以突眼及其他相关症状就诊于眼科的患者,应考虑颈动脉海绵窦瘘的可能,血管造影是该病诊断的金标准,介入手术治疗对颈动脉海绵窦瘘是安全有效的。     

Transvenous injection of Onyx for casting of the cavernous sinus for the treatment of a carotid-cavernous fistula

A complex case of carotid-cavernous fistula was treated transvenously by injection of ethyl vinyl alcohol co-polymer into the cavernous sinus after an unsuccessful embolization attempt with detachable coils and liquid adhesive agents. There were no complications. At 3 months the patients symptoms had resolved completely, and a control angiogram revealed persistent occlusion. The physical properties of ethyl vinyl alcohol polymer justify further investigation of this agent for the treatment of carotid-cavernous fistula.     

创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤的诊断和治疗

目的 探讨创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤的诊疗方法.方法 介入方法诊断和治疗6例创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤患者.结果 5例出现反复鼻腔大出血;所有患者均行瘘口和假性动脉瘤球囊闭塞,2例颈内动脉保留,1例合并对侧间接型颈动脉海绵窦瘘行经面静脉-眼上静脉瘘口弹簧圈栓塞术.术后颅内杂音均即刻消失,结膜充血水肿2周～3个月内消退.无介入相关并发症.所有患者均行随访,无临床症状复发,均恢复工作.结论 车祸是致颈动脉海绵窦瘘合并蝶窦假性动脉瘤的主要原因;受力部位多集中在患侧眶额部到眶颧部的眶前外侧区;头颅MRI结合临床表现对于术前确诊该病非常有帮助;可脱球囊闭塞瘘口和假性动脉瘤或闭塞颈内动脉是安全、有效的治疗方法.     

Myelopathy due to large veins draining recurrent spontaneous caroticocavernous fistula

Summary A 45-year-old woman developed a myelopathy 9 years after a spontaneous left caroticocavernous fistula (CCF) was treated by a trapping procedure, with clipping distal to the fistula and ligation of the common carotid artery. Spinal MRI and vertebral angiography revealed recurrence of the CCF and gigantic tortuous veins draining through the brain stem down to the midcervical spinal cord. The abnormal veins and myelopathy disappeared after surgical closure of the CCF.     

Transsphenoidal computer-navigation-assisted deflation of a balloon after endovascular occlusion of a direct carotid cavernous sinus fistula

SUMMARY: A 49-year-old woman with a direct posttraumatic carotid cavernous fistula (CCF) was treated with detachable balloons via a transcarotid route. After the procedure, her intracranial bruit, conjunctival injection, and orbital congestion were cured, but the preexistent sixth nerve palsy deteriorated. CT showed one balloon positioned in the posterior portion of the right cavernous sinus and was regarded to be responsible for nerve compression. After surgical exposure by use of a transnasal-transsphenoidal approach under 3D navigation control, this balloon was deflated by puncture with a 22-gauge needle. The previously described symptoms resolved after balloon deflation. This report presents a rare complication of endovascular treatment of direct CCF and a new microsurgical approach to a balloon in a case of nerve compression.     

特殊类型颈动脉海绵窦瘘的血管内栓塞治疗

目的　探讨特殊类型颈动脉海绵窦瘘的血管内栓塞治疗的可行性及其价值。方法 :2 8例有外伤史的患者 ,采用Seldinger技术送入导管行全脑血管造影 ,观察侧支循环情况后 ,进行血管内栓塞治疗。结果 :双侧颈动脉海绵窦瘘 6例 ;单侧者为小瘘口 4例、多发瘘口者 2例 ,瘘口部合并骨折片者 11例 ,合并创伤性动脉瘤者 3例 ;栓塞后出现NPPB者 2例。血管内栓塞治疗中 ,闭塞瘘口保持颈内动脉通畅者 9例 ,闭塞瘘口同时闭塞颈内动脉者 19例。结论 :对于特殊类型颈动脉海绵窦瘘行血管内栓塞治疗是安全、有效的 ,应为首选的方法。对于不同病例应采取特例特办的原则 ,方可取得良好的治疗效果。     

MR扩散加权成像诊断食管癌的效能

本研究目的是评价DWI对检出食管癌及评估淋巴结的价值,并与组织病理学对照。对连续24例食管癌病人前瞻性进行背景信号抑制的全身扩散加权成像（DWIBS）。将DWIBS影像与T2WI影像融合,由3名有资质的放射科医师独立盲法分析,内容包括原发肿瘤的检出能力及淋巴结状况,并测量原发肿瘤和淋巴结的表观扩散系数（ADC）。原发肿瘤的平均检出率为49．4％,以病人为目标的淋巴结转移检出的敏感度和特异度分别为77．8％和55．6％,     

Endovascular occlusion of direct carotid cavernous fistula with detachable balloons: usefulness of 3D angiography

The objective of this study is to show rotational 3D angiography findings and their usefulness in the occlusion of carotid cavernous fistulas (CCFs) using detachable balloons. Five patients with direct CCF were retrospectively reviewed for details of interventional procedures and 2D and 3D angiography findings. Pretherapeutic 2D and 3D angiograms (n=2) were compared to evaluate the size of the fistula and the relative size of the cavernous sinus with respect to the fistula. Postinflation-predetachment (n=3) and postdetachment (n=4) 2D and 3D angiograms were compared in each stage to evaluate the relative location of the balloon to the internal carotid artery (ICA), presence of a pseudoaneurysm, and relative size of the balloon to the fistula. Pretherapeutic 2D and 3D angiograms were equally effective in showing the fistula and relative size of the cavernous sinus. But, 3D angiography with cut images at arbitrary viewing angles clearly visualized the 3D relations between the ICA, fistula, and cavernous sinus. Both postinflation-predetachment 2D and 3D images in two patients equally showed a contrast-filled pseudoaneurysm outside the ICA and intraluminal location of the balloon. However, only the 3D images showed no difference in size of the balloon compared with the fistula, which was relevant to traction-induced instability in the remaining one patient. Both postdetachment 2D and 3D angiograms were equal in terms of showing ICA compromise (60%) in one patient and an extraluminal balloon location with complete fistular occlusion in two patients. In the remainder, a small pseudoaneurysm was identified only on 3D images. Three-dimensional angiography is a useful imaging tool for capturing the complex perifistular anatomy in the pretherapeutic stage, and for providing detailed information about the degree of balloon inflation and its location, the presence of a pseudoaneurysm, and the expected traction-induced instability in the predetachment stage. Postinflation-predetachment 3D angiography may therefore offer a chance to correct an erroneous manipulation that would otherwise lead to an incomplete procedural outcome and disastrous balloon migration.     

Transarterial embolisation of complex cavernous sinus dural arteriovenous fistulae with low-concentration cyanoacrylate

We report the effectiveness of low-concentration n-butyl-2-cyanoacrylate (NBCA)-Lipiodol-tungsten mixture (10–15 %) in the management of patients with aggressive or recurrent complex cavernous dural arteriovenous fistulae (CSDAVF). We treated five patients with complex CSDAVF with a low concentration of an NBCA-Lipiodol-tungsten mixture after catheterisation of the feeding arteries arising from the external carotid artery. Three had a recurrent CSDAVF after transarterial particulate embolisation. Three refused transvenous treatment or could not be treated in this way; two patients had also feeding dural branches of the internal carotid artery. All patients had complete resolution of symptoms and signs within a month of the procedure. No definite neurological complication was found during follow-up ranging from 12 to 36 months. Transarterial embolisation with low-concentration cyanoacrylate appears to be an effective alternative management of aggressive or recurrent CSDAVF. Received: 8 November 1999/Accepted: 2 March 2000     

Aqueduct stenosis due to venous ectasia with a dural arteriovenous fistula

We report aqueduct compression by venous ectasia in a 65-year-old man with a dural arterio-venous fistula in the posterior cranial fossa draining into a superior vermian vein. Conventional and phase-contrast MRI showed the aqueduct stenosis and the causative dilated vein. Received: 9 November 1998 Accepted: 2 August 1999     

重视神经介入放射专业队伍的建设和规范化培训

经过数十年的发展,介入神经放射学业已成为脑血管疾病不可或缺的治疗手段,我国的神经介入工作近年发展迅速,在许多领域达到了国际领先水平.然而由于诸多原因,我国许多从事介入神经放射诊疗工作的医师缺乏全面的训练,已越来越不适应高度专业化的工作需要,目前亟待制订规范可行的神经介入医师技术培训和资质认证体制,促进我国介入神经放射学健康、快速的发展.     

Superior petrosal sinus catheterization for transvenous embolization of a dural carotid cavernous sinus fistula

We report the endovascular treatment of a dural carotid cavernous fistula in a 67-year-old woman in whom superior petrosal sinus catheterization was performed to access the venous site of the fistula. To our knowledge, this retrograde venous route via the superior petrosal sinus has not been previously described.     

Transvenous embolization of a direct carotid cavernous fistula through the pterygoid plexus

Closure of a direct carotid cavernous fistula with detachable coils by transpterygoid venous approach to the cavernous sinus is an alternative technique that may be applied in cases in which other techniques offer increased risk or in which other techniques have failed. In this case report, we present the details of the management of a direct carotid cavernous fistula by this method.     

A rare brainstem hemorrhage due to incomplete transvenous embolization of the cavernous sinus dural arteriovenous fistula: A case report

Endovascular embolization is generally thought to be safe and effective for the cavernous sinus dural arteriovenous fistula (CS DAVF); however, some complications have been reported. We report an extremely rare brainstem hemorrhage associated with transvenous embolization (TVE) of CS DAVF. A 66-year-old man presented with right-sided conjunctival chemosis and exophthalmos. His brain magnetic resonance image showed right CS DAVF. Thus, emergent TVE was performed. Although his symptoms improved after the first TVE, magnetic resonance image showed brainstem edema, and venous congestion was suspected because of incomplete TVE. Second TVE was performed. Thereafter, computed tomography showed brainstem hemorrhage, resulting in the occurrence of right abducent nerve palsy, right-sided facial palsy, and ataxia. The patient''s condition gradually improved, and a year has passed without recurrence. Incomplete TVE of CS DAVF can result in life-threatening complications, such as cerebral hemorrhage. To avoid these complications, the anatomical structure of the cavernous sinus should be understood accurately, and important drainage veins should be determined.