Treatment of direct carotid-cavernous fistulas with detachable balloons

Experience with transarterial treatment of 14 direct carotid-cavernous fistulas using the Debrun technique with detachable balloons manually tied to the catheter is reported. Ten of the fistulas were occluded by balloons with concomitant occlusion of the internal carotid in one case. Another fistula closed spontaneously in connection with the embolization procedure. Three fistulas were treated with surgical trapping after recurrence. The transvenous approach was attempted in three cases but failed. Four complications occurred, two with clinical consequences as the patients developed neurologic deficits. Except in four cases with persistent or slowly regressing orbital palsies all signs and symptoms of the fistula disappeared after successful occlusion. The use of detachable balloons for selective occlusion is in experienced hands a rather safe and simple method with good results. Large fistulas offer most problems, and to avoid progression in fistula size the treatment should be undertaken as soon as possible after diagnosis.     

Treatment of dural carotid-cavernous fistulas via the superior ophthalmic vein

Symptomatic patients with dural carotid-cavernous fistulas often require treatment. Traditional therapies, which often are not completely successful, include manual common carotid artery compression and embolization via transarterial routes. This report describes four symptomatic patients with spontaneous dural carotid-cavernous fistulas who were treated unsuccessfully with transarterial embolotherapy and subsequently treated successfully by having a detachable balloon introduced into the cavernous sinus via the superior ophthalmic vein, which was surgically exposed. The fistulas resolved without complications. Treatment of dural carotid-cavernous fistulas by means of the transvenous approach via the superior ophthalmic vein may be of benefit in selected patients.     

Endovascular management of carotid-cavernous fistulas

Objective To investigate endovascular treatment of traumatic direct carotid-cavernous fistulas （CCF） and their complications such as pseudoaneurysms. Methods： Over a five-year period, 22 patients with traumatic direct CCFs were treated endovascularly in our institution. Thirteen patients were treated once with the result of CCF occluded, 8 twice and 1 three times. Treatment modalities included balloon occlusion of the CCF, sacrifice of the ipsilateral internal carotid artery with detachable balloon, coll embolization of the cavernous sinus and secondary pseudoaneurysms, and covered-stem management of the pseudoaneurysms. Results All the direct CCFs were successfully managed endovascularly. Four patients developed a pseudoaneurysm after the occlusion of the CCF with an incidence of pseudoaneurysm formation of 18.2% （4/22）. A total number of 8 patients experienced permanent occlusion of the ICA with a rate of ICA occlusion reaching 36.4% （8/22）. Followed up through telephone consultation from 6 months to 5 years, all did well with no recurrence of CCF symptoms and signs. Conclusion Traumatic direct CCFs can be successfully managed with endovascular means. The pseudoaneurysms secondary to the occlusion of the CCFs can be occluded with stent-assisted coiling and implantation of covered stents.     

Transarterial platinum coil embolization of carotid-cavernous fistulas

Of the 227 embolization procedures performed by our neurointerventional section for symptomatic carotid-cavernous fistulas over the past 10 years, five involved placement of platinum coils in the cavernous sinus from a transarterial route. In four patients, prior transarterial balloon procedures had failed to produce fistula closure. In the fifth patient, with Ehlers-Danlos syndrome, a prior transvenous embolization attempt was unsuccessful. In three patients, complete closure of the carotid-cavernous fistula was achieved with preservation of the parent artery. In one patient, the earliest treated, a portion of a platinum coil projected through the fistula into the parent artery. To eliminate the risk of clot formation and distal embolization, internal carotid occlusion was performed and tolerated without deficits. In the last patient, closure of the anterior drainage was achieved, but complicated by distal migration of the platinum coils with transient aggravation of ocular symptoms. Attempts to occlude the remaining cortical drainage were unsuccessful with platinum coils; therefore, a balloon was used to obliterate the small remaining fistula. Transarterial platinum coil embolization is an alternative treatment for symptomatic carotid-cavernous fistulas that cannot be closed successfully by other embolization techniques. The development of shorter, more thrombogenic, detachable or retrievable coils may make this technique more promising in the future.     

Follow-up of endovascular treatment of direct carotid-cavernous fistulas

Introduction  

Direct carotid-cavernous fistula (CCF) is a direct communication between the internal carotid artery (ICA) and the cavernous sinus. Some patients treated with detachable balloons develop pseudoaneurysms or present with a true aneurysm recanalization in the cavernous ICA with poorly known long-term radiological and clinical progression. The objective of the present study was to evaluate the long-term clinical and radiological progression of patients treated with detachable balloons.     

Delayed effects in the treatment of carotid-cavernous fistulas

Carotid-cavernous fistulas may be classified into: (1) internal carotid, (2) external carotid, or (3) a combination of both. They may result from traumatic or spontaneous rupture of the carotid artery into the cavernous sinus. Intravascular embolization has become the treatment of choice for the management of carotid cavernous fistulas. The authors report the delayed effects after the treatment of carotid-cavernous fistulas with experience of 74 cases over the past 6 years. The delayed effects may be summarized as follows: (1) progressive spontaneous occlusion of the fistula after partial balloon embolization, (2) false aneurysms may decrease in size and be spontaneously sealed off, (3) transient and persistent third or sixth cranial nerve palsy may be seen in about 16% of 74 cases, (4) posttraumatic fibrosis with narrowing of the carotid artery may be apparent after total occlusion of the fistula, (5) a prematurely deflated balloon may be dislodged into the carotid artery or its branch, and (6) spontaneous obliteration of common channels from internal carotid artery may occur after total occlusion of external carotid channels in those cases with a combination of internal carotid- and external carotid-cavernous fistulas. Certainly the delayed effect will alter our future planning in the treatment of carotid cavernous fistulas.     

MRI of dural carotid-cavernous fistulas comparisons with postcontrast CT

Ten patients with dural carotid-cavernous fistulas (CCFs) who presented with ophthalmic manifestations were studied using postcontrast computed tomography (CT), magnetic resonance imaging (MRI), and selective cerebral arteriography. The lesions of two patients were bilateral. An enlarged cavernous sinus (CS) was diagnosed in 6 of the 12 involved sides using postcontrast CT. An abnormal flow void in the CS was detectable in 11 of the 12 using MRI. A dilated superior ophthalmic vein (SOV) was demonstrated in all of the involved sides by postcontrast CT, and in 9 of the 12 by axial MRI. Thus, both postcontrast CT and MRI are relatively useful and complementary in the diagnosis of dural CCFs. Patients should be followed with selective cerebral arteriography for definitive diagnoses and for therapeutic planning.     

外伤性颈内动脉海绵窦瘘的可脱性球囊栓塞治疗

目的 探讨外伤性颈内动脉海绵窦瘘(traumatic carotid -cavernous fistulas,TCCF)可脱性球囊栓塞术的技术要点并客观评价其治疗效果. 方法 以可脱性球囊栓塞治疗59例TCCF,共进行栓塞术64次.随访时间3个月～2年. 结果 48例成功闭塞瘘口且保留颈内动脉通畅,颈内动脉通畅率为81％;11例瘘口及颈内动脉被同时闭塞.5例在治疗后3d内复发(复发率为8％),再次行栓塞术,其中1例出现栓塞后失明,再次行球囊栓塞后成功闭塞,但视力未恢复;1例术后3d出现脑内血肿,急诊再次行栓塞,闭塞颈内动脉和瘘口,但左侧肢体轻瘫. 结论 以可脱性球囊栓塞是治疗TCCF的可靠方法,具有损伤小、安全性高的特点;术后应严密观察病情,若出现复发症状,应及时复查脑血管造影及头颅CT,急诊处理复发的TCCF.     

Spontaneous carotid-cavernous fistulas: phlebographic appearance and relation to thrombosis.

Six consecutive cases with spontaneous carotid-cavernous fistulas were examined with orbital phlebography and bilateral carotid angiography. One of the fistulas was fed only by one internal carotid artery, 1 only by the accessory meningeal branch of the maxillary artery, while 4 were supplied by external as well as internal carotid arteries. The findings at phlebography seem to be characteristic. Thrombosis was demonstrated in all 6 cases. Different mechanisms for the genesis of thrombosis in association with carotid-cavernous fistulas are proposed. Alternative therapy methods are discussed.     

Dilated intercavernous sinuses: an MR sign of carotid-cavernous and carotid-dural fistulas

Dilated venous channels traversing the sella and connecting the two cavernous sinuses were seen on contrast-enhanced MR images in four patients with angiographically proved carotid fistulas. The anatomy and variations of these so-called intercavernous sinuses are discussed and are demonstrated in Latex-injected anatomic specimens. Direct visualization of the intercavernous sinuses on contrast-enhanced MR images may serve as an ancillary sign for the diagnosis of carotid-cavernous or carotid-dural fistulas near the sella.     

Willis覆膜支架治疗难治性外伤性颈动脉海绵窦瘘

目的 评价Willis覆膜支架血管内治疗难治性外伤性颈动脉海绵窦瘘(TCCF)的疗效,强调保留和重建颈内动脉(ICA)的重要性.方法 回顾性分析最近6年使用Willis覆膜支架治疗的12例外伤性TCCF,其中1例双侧瘘口.所有病例经可脱球囊治疗失败,术后1～60个月脑血管造影和临床随访评价其疗效.结果 小瘘口3个,多发...     

Bilateral direct carotid-cavernous fistulas of traumatic and spontaneous origin: two case reports

Summary In the present paper we discuss two cases with bilaterally located carotid-cavernous fistulas: one of traumatic origin and the other occuring spontaneously. Most traumatic fistulas are direct, unilateral and of a high flow type. In our first case we deal with traumatic bilateral direct fistulas with a low flow, a combination which must be considered rare and is not reported in the literature so far. In our second case there are bilaterally located fistulas, occuring spontaneously. Peculiarly they are direct, instead of indirect as is to be expected in spontaneously developing fistulas, and of a low flow type. This combination too must be considered extremely rare. In both cases conservative therapy was successful, despite their difference in etiology. It appears that neither the anatomy nor the manner of onset determines the success of conservative therapy, but the fact that a fistula is of a high- or low flow type.     

经动脉途径血管内治疗51例外伤性直接性颈动脉海绵窦瘘

目的推介最近5年经动脉途径使用可脱球囊、弹簧圈和Willis覆膜支架血管内治疗外伤性直接性颈动脉海绵窦瘘(TDCCFs)和保留颈内动脉(ICA)的经验。方法回顾性分析经动脉途径血管内治疗的51例患者的54处TDCCFs,均首选可脱球囊作为治疗方法,Willis覆膜支架和弹簧圈作为备选方法,术后3～48个月行脑血管造影和临床随访评价所有患者的治疗效果。结果一期单纯性可脱球囊成功治疗46处(85.2%)TDCCFs,并保留了ICA。使用可脱球囊、弹簧圈和Willis覆膜支架合计保留了53处(98.1%)TDCCFs的ICA,同时成功闭塞瘘口,仅1例闭塞了单侧ICA和瘘口。单纯可脱球囊治疗40处TDCCFs,单纯Willis覆膜支架治疗2处TDCCFs,单纯弹簧圈治疗1处TDCCF,可脱球囊联合Willis覆膜支架治疗8处TDCCFs,联合弹簧圈治疗3处TDCCFs,其中1处使用了Willis覆膜支架治疗。12处TDCCFs进行了二期和三期治疗。除外5例患者单侧视力损害和(或)脑神经麻痹无明显改善外,术后1 d～6个月其他病例症状呈阶梯型改善,直到消失。术中无一例患者血管破裂、无远端脑栓塞和新发神经系统症状等并发症...     

Endovascular treatment strategy for direct carotid-cavernous fistulas resulting from rupture of intracavernous carotid aneurysms

BACKGROUND AND PURPOSE: Reported treatments and outcomes in aneurysmal carotid-cavernous fistulas (CCFs) have been admixed with those of cases considered to be symptomatic of intracavernous aneurysm. However, aneurysmal CCFs have clinical features distinct from those of dural arteriovenous fistulas, and treatment strategies similar to those of traumatic CCF are required. We evaluated our experience in placing detachable balloons in the management of spontaneous CCFs due to rupture of an intracavernous aneurysm. METHODS: Six patients (one man, five women; mean age, 64.7 years) were treated for spontaneous direct CCF at our institution between 1995 and 2001. All patients presented with sudden ocular symptoms including exophthalmos, conjunctival injection, chemosis, and ocular motor palsies. Detachable latex balloons were used as the embolic material in five patients, and in one patient the cavernous sinus was packed transarterially with coils. RESULTS: All six patients were successfully treated by means of transarterial embolization, and symptoms improved within a week. CONCLUSION: Although other techniques using a transvenous approach and/or detachable coils may also be useful, embolization with detachable balloons should be a safe and effective method to immediately occlude the fistula.     

Transvenous treatment of spontaneous dural carotid-cavernous fistulas using a combination of detachable coils and Onyx

Three patients with spontaneous dural carotid-cavernous fistulas were treated by using a combination of detachable coils and Onyx liquid embolic agent. Cavernous sinus was accessed via the superior ophthalmic vein or inferior petrous sinus approach. In all cases, a complete angiographic closure of the fistulas was achieved with full recovery from neuro-ophthalmologic symptoms. This report suggests that the controlled and excellent penetration of Onyx is superb for blocking the intricate communication of dural carotid-cavernous fistulas.     

Treatment of vertebral arteriovenous fistulas

Twenty patients with vertebral arteriovenous fistulas (eight spontaneous, six traumatic without vertebral artery transection, and six traumatic with vertebral artery transection) were treated by transvascular embolization techniques, resulting in complete fistula closure in all patients. The fistulas were located at C1-C2 in 45%, C2-C3 in 25%, C4-C5 in 15%, C5-C6 in 10%, and C6-C7 in 5%. Trauma was the most common cause: 30% followed knife wounds, 20% followed gunshot injuries, and 10% followed blunt trauma. Eight patients had spontaneous fistulas, two associated with fibromuscular dysplasia. Three patients-all with large, long-standing fistulas-developed neurologic deficits coincident with the abrupt closure of the fistula, which resolved with reestablishment of fistula flow. Two of these patients were treated by staged closure; the other one by gradual closure. In all three cases the result was complete fistula closure without neurologic sequelae. The remaining spontaneous fistulas were all closed by balloon embolization with preservation of the vertebral artery and without deficits. The six patients with traumatic fistulas without transection were cured by balloon embolization, without deficits; in four there was also preservation of vertebral flow. The other six patients had traumatic fistulas with transection and were all cured by balloon embolization with preservation of flow in two. Four patients required bilateral approaches to the fistula to achieve complete fistula closure. The only complication was a mild residual Wallenberg syndrome after occlusion of the posterior inferior cerebellar artery in the treatment of a transection located at C1. In our opinion, transvascular techniques are the treatment of choice for vertebral arteriovenous fistulas.     

Treatment of traumatic carotid-cavernous fistula using detachable balloon catheters

The goal of therapy in patients with traumatic carotid-cavernous fistulas is to occlude the fistula, preferably while maintaining the carotid blood flow. Surgical techniques that treat the fistula remote from the cavernous sinus often cannot maintain carotid patency. Various interventional techniques using detachable balloons have been developed. The most common technique uses the endarterial route, introducing the balloon catheter in the neck or the groin. If the balloon is detached in the cavernous sinus, the carotid blood flow will be preserved. A second approach uses the venous retrograde route through the jugular vein, inferior petrosal sinus, and cavernous sinus. Elegant and safe, this method is appropriate when the fistula drains posteriorly. A third approach involves surgical exposure of the cavernous sinus and direct introduction of the balloon. This is sometimes the only recourse when the fistula has been previously treated with internal carotid ligation.