Spontaneous obliteration of a carotid-cavernous fistula associated with fibromuscular dysplasia of the internal carotid artery

The authors present a case of spontaneous recovery of a carotid-cavernous fistula associated with fibromuscular dysplasia of the aortocranial vessels in a 31-year-old woman. The pathogenesis of the carotid-cavernous fistula and the possible mechanism responsible for its spontaneous obliteration are both discussed.     

Direct intracavernous obliteration of high-flow carotid-cavernous fistulas

Four cases of high-flow carotid-cavernous sinus fistula (CCF), three of them posttraumatic and one spontaneous, have been treated by a direct surgical approach to the cavernous sinus. The CCF's were obliterated by the introduction into the cavernous sinus of muscle fragments and/or fibrin sealant. In the three cases with a preoperatively patent internal carotid artery (ICA), the CCF was occluded and the ICA flow preserved. One of these also had a posttraumatic false aneurysm that enclosed the two avulsed ends of a transected intracavernous ICA. This was treated by cervical ICA ligation following resolution of the CCF. A fourth patient, who had previously undergone an unsuccessful ICA trapping procedure elsewhere, also obtained a good result. The case histories and the surgical technique are presented. Direct intracavernous obliteration with muscle fragments and fibrin sealant fulfills the criteria for treatment of high-flow CCF's: occlusion of the arteriovenous fistula and preservation of the ICA circulation. While this surgical technique is a therapeutic option in some cases, it appears to have precise indications in others.     

Spontaneous development of an intracavernous arterial aneurysm into a carotid-cavernous fistula. Case report

Summary The case report here deals with an intracavernous arterial aneurysm spontaneously developing into a carotid-cavernous fistula. The aetiopathology of these fistulas is discussed.     

Dural carotid-cavernous sinus fistula and central retinal vein occlusion: a case report and a review of the literature

A case of dural carotid-cavernous sinus fistula was complicated by hemorrhagic retinopathy due to central retinal vein occlusion. A 57-year-old woman with a dural carotid-cavernous sinus fistula was initially treated by transarterial particulate embolization. Her symptoms subsequently improved, but 4 months later she gradually developed decreased visual acuity due to central retinal vein occlusion. A review of the literature showed that central retinal vein occlusion may be more common than previously thought. Dural carotid-cavernous sinus fistulas should be treated and followed taking into account possible complication by central retinal vein occlusion. Early detection of central retinal vein occlusion by frequent ophthalmologic examinations may prevent deterioration of visual acuity.     

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.     

Iatrogenic carotid-cavernous fistula following Fogarty catheter thromboendarterectomy. Case report.

A case of iatrogenic carotid-cavernous fistula secondary to a Fogarty catheter thrombectomy is presented. The literature and seven previously reported cases are reviewed.     

Direct approach to a traumatic giant internal carotid artery aneurysm associated with a carotid-cavernous fistula. Case report.

The case is reported of a giant intracranial internal carotid artery aneurysm associated with a carotid-cavernous fistula following a closed head injury. The aneurysm and the fistula disappeared after only the neck of the aneurysm was clipped. This is the first case in which a direct surgical approach was successful in sparing the internal carotid flow. Reports of similar cases are reviewed.     

Transarterial detachable coil embolization combined with ipsilateral intermittent carotid oppression for traumatic carotid-cavernous fistula with small fistula

One case of traumatic carotid-cavernous fistula (TCCF) with small fistula treated by transarterial detachable coil embolization was reported. The intermittent ipsilateral carotid compression was used to identify the final blocking of the residual fistula. The follow-up digital subtraction angiography showed that the TCCF was cured finally. From this case, we conclude that this method may be an effective way to treat TCCF with small fistula.     

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.     

Intracerebral venous hemorrhage in "high-risk" carotid-cavernous fistula

Intracerebral hematoma associated with carotid-cavernous fistula is a rare occurrence. Based on a review of the literature and on the analysis of personal observation, the authors define as "high-risk fistula" a carotid-cavernous fistula at risk of intracerebral hemorrhage. Characteristic features of these are computed tomography demonstration of parenchymal vermicular enhancement of brain vessels, and an angiographic pattern of dilated and tortuous cerebral veins. When an intracerebral hemorrhage occurs in a patient with carotid-cavernous fistula an early but phased and combined neuroradiological-neurosurgical approach is suggested as the best way to treat this life-threatening situation.     

Fatal paradoxical muscle embolization in traumatic carotid-cavernous fistula repair. Case report.

A unique case of fatal paradoxical muscle embolism in a patient with a traumatic carotid-cavernous fistula is described. The muscle plug intended to occlude a left-sided fistula passed through the large fistula, bypassed the lungs by way of a patent foramen ovale, and embolized through the right carotid artery to lodge the internal carotid and middle cerebral arteries producing fatal brain infarction.     

Carotid-cavernous fistula caused by a ruptured intracavernous aneurysm: endovascular treatment by electrothrombosis with detachable coils.

A case of carotid-cavernous fistula caused by a ruptured intracavernous aneurysm is reported. The fistula was treated with electrothrombosis by the detachment of two platinum coils into the aneurysm via an endovascular transvenous approach; the fistula was closed, and the patient has recovered completely. The advantages of using electrodetachable platinum coils include thrombogenicity, controllable deposit, radiopacity, and biocompatibility.     

Medical postoperative management of massive conjunctival prolapse: a case report

A severe case of conjunctival prolapse secondary to a posttraumatic carotid-cavernous fistula is presented. Management with a humid chamber and topical ointments obviated surgical intervention that might have compromised the inferior cul de sac.     

Traumatic aneurysm of the anterior cerebral artery associated with a contralateral carotid-cavernous fistula: a case report

An unusual case of traumatic aneurysm of the A-1 part of the anterior cerebral artery associated with a contralateral carotid-cavernous fistula is presented. Trapping of the fistula was carried out, and an attempt to repair the vessel wall was made. Thrombosis of the vessel occurred, but remained asymptomatic. Causes, physiopathology, and treatment of traumatic aneurysms are discussed.     

Conservative treatment of a traumatic direct low-flow carotid-cavernous sinus fistula: A case report

Summary A case of a 17-year-old boy presenting with a traumatic carotid-cavernous sinus fistula (CCSF), associated with an intracavernous pseudo-aneurysm, is reported. On angiography, the CCSF proved to be a direct and low-flow shunt. Conservative management was chosen and definitive closure of the fistula was obtained in two months by daily self-compression of the common carotid artery.     

Indirect carotid-cavernous sinus fistula: transvenous embolization from the external jugular vein using a superior ophthalmic vein approach. A case report

A case of indirect carotid-cavernous sinus fistula treated by combined transarterial and transvenous embolization is described. A 49-year-old woman with a right indirect carotid-cavernous sinus fistula draining solely to the right superior ophthalmic vein was treated first by transarterial embolization with polyvinyl alcohol particles. Then, by approaching through the superior ophthalmic vein from the right external jugular vein, the cavernous sinus was embolized with platinum wire using a tracker microcatheter, which resulted in marked clinical improvement. Transvenous embolization by approaching from the external jugular vein through the superior ophthalmic vein represents a promising alternative when shunted blood drains anteriorly to the superior ophthalmic vein.     

A case of spontaneous carotid-cavernous fistula disappearing following irradiation

A case of spontaneous carotid-cavernous fistula, which completely disappeared following irradiation (45 Gy), is reported. A 59-year-old woman was admitted on October 10, 1983, with a history of doplopia and recurrent retrobulbar and occipital pain. On admission, neurological examination showed no neurological deficit, and right cerebral angiography demonstrated a dural internal carotid-cavernous fistula fed by the meningohypophyseal trunk and drained into the inferior petrosal sinus. In spite of the conservative management, right oculomotor palsy and hypesthesia corresponding to the division of ophthalmic branch of the right trigeminal nerve was developed. On November 22, liniac irradiation to the region of fistula (30 days, total dose, 45 Gy) was started. Symptoms and signs gradually improved 3 weeks after irradiation and completely disappeared 3 months after irradiation. Carotid-cavernous fistula was no longer demonstrated by the cerebral angiography 7 months after irradiation. Two years after onset, no recurrence of symptoms was observed.     

Carotid-cavernous fistula treatment with ethylene vinyl alcohol (onyx) exclusively through anterior venous approach

The type of venous drainage of a direct carotid-cavernous fistula is an important issue to consider for the endovascular therapeutic decision. In case of an inadequate posterior drainage associated with a good anterior drainage, the facial vein is a useful alternative. The exclusive embolization with ethylene vinyl alcohol (EVOH Onyx), arterial and/or venous via the internal carotid artery (ICA) occlusion has been used successfully, in a few cases until now. Nevertheless, the use of this method through anterior transvenous approach has not been previously described. Presented here is the case of a 13-year-old female patient with left posttraumatic carotid-cavernous fistula, with predominant anterior drainage, as well as carrier of traumatic occlusion of the contralateral ICA. The treatment was by means of a transvenous approach with transient occlusion of the left ICA.     

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.     

Return of vision after transarterial coiling of a carotid cavernous sinus fistula: case report

BACKGROUND: Carotid cavernous sinus fistulae are abnormal communications between the carotid circulation and cavernous sinus that may arise spontaneously or develop after craniocerebral trauma. They may present with a constellation of signs and symptoms characteristic of raised cavernous sinus pressure, including orbital or retro-orbital pain, pulsatile proptosis, chemosis, ocular or cranial bruit, deterioration of visual acuity, or ophthalmoplegia. Visual loss is likely the result of multiple insults to the visual system, including reversal of venous drainage from the fistula, arterial flow into the superior ophthalmic vein, increased intraocular venous pressure, venous stasis retinopathy, and eventually ischemic optic neuropathy [Brodsky MC, Hoyt WF, Halbach VV, et al. Recovery from total monocular blindness after balloon embolization of carotid-cavernous fistula. Am J Ophthalmol 1987;104:86-87; Sanders MD, Hoyt WF. Hypoxic ocular sequelae of carotid-cavernous fistulae: study of the causes of visual failure before and after neurosurgical treatment in a series of 25 cases. Br J Ophthalmol 1969;53:82-97]. CASE DESCRIPTION: With few exceptions, the literature is replete with evidence of persistent blindness despite successful treatment of the CCF [Albuquerque FC, Heinz GW, McDougall CG. Reversal of blindness after transvenous embolization of a carotid-cavernous fistula: case report. Neurosurgery 2003;52:233-237; Brodsky MC, Hoyt WF, Halbach VV, et al. Recovery from total monocular blindness after balloon embolization of carotid-cavernous fistula. Am J Ophthalmol 1987;104:86-87; Weinstein JM, Rufenacht DA, Partington CR, et al. Delayed visual loss due to trauma of the internal carotid artery. Arch Neurol. 1991;48:490-497]. Here, we report a patient who experienced recovery of vision after endovascular obliteration of the offending CCF. DISCUSSION: To our knowledge, this is the second reported case of recovery of visual function in a patient presenting with loss of light perception after treatment of a direct CCF.