Intraoperative use of Doppler to detect successful obliteration of carotid-cavernous fistulas. Technical note.

The authors describe their use of a Doppler flow detector in the treatment of carotid-cavernous fistulas to monitor the ocular bruit, the clinical sign usually used to detect obliteration of the fistula. In seven procedures the Doppler ultrasonic flow detector has yielded satisfactory proof that the flow sounds were no longer audible, and that the surgery was successful.     

Direct puncture of the cavernous sinus for obliteration of a recurrent carotid-cavernous fistula

The authors report direct transcutaneous puncture of the cavernous sinus through an intact orbit for embolization of a recurrent carotid-cavernous fistula (CCF) after 10 prior operations. The fistula was obliterated completely with this technique. No significant complication was noted except temporary ptosis for about 2 months. When other approaches are difficult or impossible, this technique can be an alternate way to treat a recurrent CCF after a trapping procedure.     

Direct carotid-cavernous sinus fistula due to ruptured intracavernous aneurysm treated with electrodetachable coils--case report

A 66-year-old female developed exophthalmos, impaired visual acuity (perception of light), and diplopia one day after sudden onset of headache. Neurological examination revealed proptosis, chemosis, impaired vision, and ophthalmoplegia. Carotid angiography showed direct carotid-cavernous sinus fistula concomitant with an intracavernous aneurysm on the right side. Intraaneurysmal embolization using the Guglielmi detachable coils (GDCs) via the transarterial route was performed and complete occlusion of the fistula successfully achieved. The neurological deficits resolved completely by 6 months after embolization. Intraaneurysmal GDC embolization via the transarterial route may be an alternative for the treatment of direct carotid-cavernous sinus fistula due to rupture of intracavernous aneurysm.     

Irradiation of spontaneous carotid-cavernous fistulas

Two patients with spontaneous carotid-cavernous fistulas were successfully treated with cobalt 60 irradiation to the sellar region. Angiographically, one patient showed combined-type shunts comprising a dural internal carotid-cavernous fistula and a direct internal carotid-cavernous fistula; the other patient had a mixed dural external and internal carotid-cavernous fistula. The respective total radiation dose was 3,200 rads and 3,024 rads. The patients responded satisfactorily to the treatment, with disappearance of the fistulas on angiograms and patency of the internal and external carotid arteries.     

Direct carotid sinus approach to treatment of bilateral carotid-cavernous fistulas. Case report

The authors present a patient with a complex vascular malformation composed of bilateral spontaneous carotid-cavernous fistulas (CCF's). The abnormality was supplied on the right side by the right external carotid artery (ECA) and the right internal carotid artery (ICA), and on the left side only by the left ICA. There was also an arteriovenous communication between the right ECA and the lateral sinus. Surgical embolization of both cavernous sinuses with oxidized cellulose was achieved on one side by direct puncture and on the other through one of its venous affluents, successfully occluding both CCF's and preserving the patency of both ICA's without any neurological deficit. The arteriovenous communication between the right ECA and the lateral sinus was occluded by embolization of the occipital artery and ligation of the right ECA.     

Treatment of 54 traumatic carotid-cavernous fistulas

A series of 54 traumatic carotid-cavernous fistulas has been treated with detachable balloon catheters. The balloon was introduced through one of three different approaches: the endarterial route; the venous route through the jugular vein, the inferior petrosal sinus, and the cavernous sinus; or surgical exposure of the cavernous sinus; with occlusion of the fistula by a detachable balloon directly positioned in the cavernous sinus. Full follow-up review demonstrated that the carotid blood flow was preserved in 59% of cases. The most frequent complication was a transient oculomotor nerve palsy, which occurred in 20% of cases. In three cases where both the fistula and the carotid artery were originally occluded by the balloon, the superior portion of the fistula was later found not to be completely occluded, and these patients had intracranial ligation of the supraclinoid portion of the carotid artery. Three patients had hemiparesis, transient in two cases and permanent in the other. The results show that the fistula was totally occluded in 53 cases; in the one exception the patient became asymptomatic but had a minimal angiographic leak.     

经动脉栓塞治疗颈内动脉海绵窦瘘的疗效

目的分析颈内动脉海绵窦瘘患者经动脉栓塞治疗的疗效。方法回顾性分析我院经动脉栓塞治疗的52例颈内动脉海绵窦瘘患者资料,分析其治疗的成功率、复发率及并发症,并随访其短期及长期疗效。结果 52例患者中,48例(48/52,92.31%)栓塞成功,4例栓塞失败后行外科手术治疗。48例栓塞成功患者中,41例(41/48,85.42%)成功闭塞瘘口且保持颈内动脉通畅。4例(4/52,7.69%)术后复发,分别经压颈、球囊、液态胶栓塞及闭塞颈动脉的方法治疗成功。44例无复发患者短期内所有患者眼部症状缓解,长期随访中无复发病例。结论经动脉栓塞治疗颈内动脉海绵窦瘘成功率高、复发率低,并发症少。可脱球囊栓塞为其首选方法,辅以弹簧圈、液态胶栓塞,其短期及长期疗效均可肯定。     

Classification and treatment of spontaneous carotid-cavernous sinus fistulas

An anatomical-angiographic classification for carotid-cavernous sinus fistulas is introduced and a series of 14 patients with spontaneous carotid-cavernous sinus fistulas is reviewed to illustrate the usefulness of such a classification for patient evaluation and treatment. Fistulas are divided into four types: Type A are direct high-flow shunts between the internal carotid artery and the cavernous sinus; Type B are dural shunts between meningeal branches of the internal carotid artery and the cavernous sinus; Type C are dural shunts between meningeal branches of the external carotid artery and the cavernous sinus; and Type D are dural shunts between meningeal branches of both the internal and external carotid arteries and the cavernous sinus. The anatomy, clinical manifestations, angiographic evaluation, indications for therapy, and therapeutic options for spontaneous carotid-cavernous sinus fistulas are discussed.     

On posttraumatic intracavernous false aneurysms and arteriovenous fistulas

Summary Posttraumatic high-flow communications between the intracavernous internal carotid artery (ICA) and the cavernous sinus may give rise to two different pathological entities. A connection between the ICA and one of the adjacent intracavernous veins will result in a carotico-cavernous fistula (CCF). A false aneurysm will develop if the arterialized rent from the injured ICA flows directly into the bare perivenous spaces within the cavernous sinus, without a shunt with one of the veins. A CCF and a false aneurysm can be present in the same patient. Angiographically these two entities may be demonstrated, and clinically have a somewhat different behaviour. Lifethreatening massive epistaxis is the most serious complication, particularly in false intracavernous aneurysms. Most high-flow CCFs are the result of a small side-wall laceration of the ICA, while large ICA injuries or even complete transection of the artery are responsible for the origin of false aneurysms.     

Pathogenetic and therapeutic considerations of carotid-cavernous sinus fistulas

Summary Carotid-cavernous sinus fistula (CCF) is a syndrome in which arteriovenous shunts exist between the carotid artery and the cavernous sinus. These shunts vary widely in pathogenesis, angiogram, haemodynamics and treatment. Several systems of classification in terms of either haemodynamics, aetiology and/or pathogenesis have been reported, but they are not comprehensive. A more comprehensive and simpler nomenclature of classification is now required.Fifty seven cases of CCFs were analyzed and were classified according to their pathogenesis, angiography and treatment modalities. There were 11 traumatic CCFs with direct shunts (T-D group), and 2 traumatic CCFs with indirect shunts (T-I group). Spontaneous CCFs were divided into three groups. There were 37 spontaneous CCFs caused by dural arteriovenous shunts that were naturally classified as being indirect shunts (SD-I group). There were 5 spontaneous CCFs caused by suspected connective tissue disorders, such as fibromuscular dysplasia, Ehlers-Danlos syndrome etc.; these had direct shunts. Care was needed to avoid dissection of the artery or complications due to the fragility of connective tissue (SC-D group). There were 2 spontaneous CCFs caused by the rupture of an inflaclinoid aneurysm without any background of connective tissue disorder; these had direct shunts (SA-D group).By this system of grouping and use of abbreviations, each case of CCF can be clearly delineated in terms of its pathogenesis and selection for appropriate treatment.     

Thermography in the management of carotid-cavernous fistulas.

The authors report their experiences with thermography as a new tool to assess the diagnosis and postoperative control of patients with carotid-cavernous fistulas (CCF). A zone of increased temperature on the homolateral orbital region is described in cases of CCF. A supraorbital "cool" area, as seen in patients with carotid stenosis or occlusion, is observed when surgery with the Jaeger-Hamby technique has been successful. Thermograms obtained in five patients are presented and the pathophysiology of these findings is discussed.     

Iatrogenic carotid-cavernous fistulas, complications of carotid thrombectomy

The authors report four cases of carotid cavernous fistula at the C5 segment of the internal carotid artery following embolectomy by a 3F Fogarty Catheter. All patients were operated on a carotid bifurcation stenosis (pre-occlusive) and a thrombectomy with a 3F Fogarty Catheter was carried out in the same time in 3 patients and during re-operation in 1 patient who had post operative thrombosis. The carotid-cavernous fistula occurred the day after surgery in 2 cases, 1 week after in 1 case, and 2 months later in 1 case. Spontaneous recovery occurred in two patients (1 occlusion--1 re-stenosis), 1 patient died from controlateral carotid occlusion, and 1 patient was lost for investigation. There were no relationship between the number of "repeated passages" of the Fogarty Catheter and the interval time where the fistula occurred. However the location of fistula was constant. Overtension on the internal wall of the artery by the balloon could be advocated rather than a collateral torn of the intra cavernous internal carotid. Endoluminal treatment of various vascular lesion is increasingly used and iatrogenic problems as reported here should be kept in mind. Age and atheromatous lesion of carotid siphon appear to be the main risk factors.     

Treatment of carotid-cavernous fistulas associated with Ehlers-Danlos syndrome

Four patients with Ehlers-Danlos syndrome presented spontaneously with symptomatic direct carotid-cavernous fistulas. Two had previously (2 and 15 years, respectively) had contralateral carotid-cavernous fistulas that were treated with carotid occlusion procedures. The patients' ages at presentation ranged from 19 to 49 years, with a mean of 32 years. All four patients underwent attempted embolization procedures. Two patients had transarterial embolization, one with balloons and liquid adhesives, one with platinum coils and a balloon; the carotid artery was preserved in one and sacrificed in one other. In one patient, who underwent direct puncture of the carotid artery, a massive hematoma causing airway compromise required intubation and emergent surgical repair. The fistula spontaneously closed during this event. In the fourth patient, two transvenous embolizations resulted in markedly decreased flow, but diversion of residual flow to cortical veins produced a fatal pontine hemorrhage. The vascular fragility associated with Ehlers-Danlos syndrome can produce spontaneous direct carotid-cavernous fistulas and makes both diagnostic and therapeutic procedures more difficult.     

Long-term observations in cases with spontaneous carotid-cavernous fistulas

Summary Twenty-six cases with spontaneous carotid-cavernous fistulas were followed up for periods ranging between 4 months and 9 years 8 months. A complete regression of symptoms without reappearance for more than 6 months was noted in 19 cases, a marked improvement in 2 cases, and a moderate regression in 3 cases. In 2 cases, symptoms have continued for 9 years 8 months and for 1 year. The regression of symptoms was usually delayed in patients less than 60 years old, in cases in which the symptoms developed slowly, and in cases with multiple draining veins. According to our observations a regression of symptoms may occur after very slight changes of haemodynamics.Compression of the cervical carotid artery for a short time or a temporary occlusion of the carotid artery by a balloon catheter should be considered as the treatment of choice in the first instance in cases with spontaneous carotid-cavernous fistulas showing relatively low pressure and low flow shunt.     

Treatment of carotid-cavernous fistulas by cavernous sinus occlusion.

The author reports the occlusion of 33 carotid-cavernous fistulas in 31 patients using thrombogenic techniques. In one patient the carotid artery had been occluded previously, in one it was occluded deliberately, and with 31 fistulas it was preserved. There was no mortality and virtually no morbidity.     

Long-term observations in cases with spontaneous carotid-cavernous fistulas

Twenty cases with spontaneous carotid-cavernous fistulas were followed up for periods ranging between 9 months and 9 years 8 months. In five cases, a temporary reappearance of symptoms was noted within 6 months after their regression. A complete regression of symptoms without reappearance for more than 6 months (between 6 months and 6 years 10 months) was noted in 18 cases, and a marked improvement was noted in one case. The regression of symptoms was usually delayed in patients less than 60 years old, in cases in which the symptoms developed slowly, and cases with three draining veins. According to these observations, noninvasive treatment is basically recommended in cases with spontaneous carotid-cavernous fistulas.