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.     

Successful treatment using detachable coils for traumatic carotid cavernous fistula as a complication of transsphenoidal surgery for a pituitary adenoma: a case report

We report a case of a patient with traumatic carotid cavernous fistula (CCF) caused by transnasal-transsphenoidal surgery, who was successfully treated using detachable coils. A 47-year-old man was admitted to our hospital because of severe headache. He was confirmed to have a nonfunctioning pituitary adenoma with presellar-type sphenoid sinus. Cerebral angiography initially disclosed no vascular lesions. A transnasal-transsphenoidal adenomectomy was performed. When the anterior wall of the sphenoid sinus was dissected with a chisel, the chisel deeply stuck into the posterolateral part of the sinus. Profuse arterial bleeding was observed through the sphenoid sinus. The bleeding was stopped easily by compression and packing with bone wax. The operation was continued, the sellar floor was opened widely and the tumor was removed subtotally. The medial wall of the cavernous sinus was intact. Histological examination revealed a pituitary adenoma. Immediately after surgery, the patient noticed a bruit. He developed chemosis and abducent palsy on the right side. Cerebral angiography displayed a high-flow CCF, which was attributed to the carotid artery injury caused by the transnasal-transsphenoidal surgery. The CCF disappeared after two-staged embolization using detachable coils, 1st transvenous and 2nd transarterial. Ten months later, cerebral angiography showed persistent occlusion of the fistula, and the patient experienced no tumor recurrence. It is suggested that drilling is a safer procedure than using a chisel for dissection of a sphenoid sinus with incomplete pneumatization. Endovascular treatment using detachable coils proved useful to manage the CCF, an unusual complication of transsphenoidal surgery.     

Transvenous balloon occlusion of the cavernous sinus: an alternative therapeutic choice for recurrent traumatic carotid-cavernous fistulas

We report a case of traumatic carotid-cavernous fistula (CCF) that recurred some 9 years after carotid trapping. The recurrent CCF was accompanied by a huge aneurysmal dilatation of the cavernous sinus. Transarterial balloon occlusion of the proximal internal carotid artery failed to occlude the fistula completely because of collateral flow to the fistula. the fistula was completely occluded by a transvenous approach via the jugular vein and inferior petrosal sinus using detachable balloons. The transjugular-inferior petrosal approach to the cavernous sinus can be an alternative for the treatment of traumatic CCF when the transarterial approach has failed to occlude the cavernous sinus.     

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.     

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.     

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.     

Dural arteriovenous fistula involving the cavernous sinus as the cause of intracerebral venous hemorrhage: a case report

A case of cavernous sinus dural arteriovenous fistula (CS-DAVF) presenting intracerebral venous hemorrhage was reported. An 81-year-old woman was suffered from generalized convulsion accompanied by right conjunctival hyperemia and edema. Computed tomography scan revealed intracerebral hematoma involving right putamen and perifocal edema extraordinarily expanded to inferior part of the right frontal lobe and insular cortex. Cerebral angiography showed a CS-DAVF with retrograde leptomeningeal venous drainage (RLVD) not only to superficial middle cerebral vein but to basal vein of Rosenthal (BVR). Transvenous embolization was performed using mechanically detachable coils and free fibered platinum coils. After embolization, RLVD disappeared and conjunctival symptoms were improved. Hemorrhagic risk of this patient was discussed, based on her angiographical findings. We speculated that deep venous drainage to BVR through uncal vein, in case with poor venous collateral geometry, is one of the risk factor of cerebral hemorrhage.     

A successful treatment of spontaneous carotid cavernous fistula causing hemorrhagic infarction treated by detachable balloon

A rare case of hemorrhagic infarction associated with carotid-cavernous fistula is reported. The patient was a 74-year-old female. CT scan showed hemorrhagic infarction of the left superior temporal gyrus, irregular vascular enhancement of the bilateral front-temporal lobe, and dilatation of the cavernous sinus. Left carotid angiogram revealed a high-flow left-sided CCF, cross filling to the right cavernous sinus, and intracavernous aneurysm. Bilateral front-temporal cortical veins were visualized early in the arterial phase. In this case, there was a direct shunt between the internal carotid artery and the cavernous sinus, and venous hypertension. Therefore urgent treatment using detachable balloon catheters was performed. Postoperative digital subtraction angiography revealed the disappearance of CCF. In conclusion, in CCF with cortical venous drainage there is a high possibility of developing hemorrhagic infarction. Only immediate detachable balloon occlusion can improve the outcome in elderly patients.     

Cerebellar hemorrhage and subsequent venous infarction followed by incomplete transvenous embolization of dural carotid cavernous fistulas: a rare complication: case report

Endovascular therapy for dural carotid cavernous fistulas (CCFs) is generally accepted to be safe and effective. The authors report a rare complication of hemorrhage and subsequent venous infarcts of the pons and cerebellum after transvenous embolization. This 41-year-old man presented with a severe left frontal headache, congestion of the left conjunctiva, blurred vision, and photophobia. Cerebral angiography demonstrated a right dural CCF. The patient underwent transvenous embolization of the cavernous sinus but had the initial complication of cerebellar hemorrhage. One month later, he developed progressive dizziness, ataxia, and right-sided weakness. Magnetic resonance imaging revealed severe cerebellar and pontine edema. The cause was a residual fistula combined with delayed occlusion of the inferior petrosal sinus. The fistula was obliterated after repeated embolizations. The patient's symptoms gradually resolved, and there was no evidence of recurrence during the 4-year follow-up period. Incomplete transvenous embolization of a dural CCF can result in life-threatening vascular complications due to redistribution of shunt flow. Early recognition of redistributed drainage and preventive placement of coils at the origin of draining veins during the procedure could avert this rare complication.     

Treatment of spontaneous carotid-cavernous fistula by the transvenous approach via the facial and angular route]

We report a case of a patient with a spontaneous carotid-cavernous sinus fistula (CCF) who was successfully treated by the facial vein approach. This 66-year-old female had a 3-month history of right chemosis and exophthalmos. Angiograms showed a spontaneous right CCF with primary drainage via the superior ophthalmic vein. As both inferior petrosal sinuses were hypoplastic, the transvenous approach could not be used to gain access to the right cavernous sinus. With effort, we were able to traverse the sharp angle at the corner of the angular vein and the superior ophthalmic vein with a microcatheter. Thereafter, it was easily navigated into the right cavernous sinus. Successful placement of Guglielmi detachable coils resulted in complete closure of the fistula. When it is difficult to gain access to the cavernous sinus via the inferior petrosal sinus, the facial vein approach is a useful alternative.     

Venous rupture during transvenous approach to a carotid-cavernous fistula. Case report

An attempt at transfemoral transarterial balloon occlusion of a high-flow spontaneous carotid-cavernous fistula was unsuccessful because the carotid artery rent was too small for this approach. During a subsequent transvenous approach to the cavernous sinus through the jugular vein, the inferior petrosal sinus was perforated. A minor subarachnoid hemorrhage occurred before the tear could be sealed by the deposition of three Gianturco coils in the vein. The patient was taken to the operating room for emergency obliteration of the fistula and petrosal sinus in order to remove the risk of further hemorrhage. Under the guidance of intraoperative digital subtraction angiography, isobutyl-2-cyanoacrylate was injected directly into the surgically exposed cavernous sinus. Successful obliteration of the fistula was achieved with preservation of the carotid artery, and the angiography catheter was removed safely from the petrosal sinus. Although initially after surgery the patient had nearly complete ophthalmoplegia, at her 1-year follow-up examination she had normal ocular motility and visual acuity. The transvenous approach to the cavernous sinus and alternative methods of treatment of carotid-cavernous fistulas are discussed.     

A novel approach to direct carotid cavernous fistula repair: HydroCoil-assisted revision after balloon reconstruction

BACKGROUND: Direct carotid cavernous fistulae (CCF) are commonly treated by endovascular deployment of a detachable balloon into the cavernous sinus to reconstruct the sidewall of the carotid artery and preserve flow in that vessel. Relatively few reports exist describing revisions using constructive, transarterial approaches when this technique fails. METHODS: We describe a novel method using expandable hydrogel-coated platinum coils to revise a failed balloon reconstruction in which the balloon had migrated within the cavernous sinus away from the rent in the carotid wall. RESULTS: This new technique to buttress the balloon back into the desired position using expandable coils proved to be effective, safe, and durable. CONCLUSIONS: As endovascular treatments for direct CCF continue to evolve, techniques for revision will likely follow. This report adds a novel approach to our therapeutic armamentarium.     

Traumatic carotid-cavernous sinus fistula associated with an intradural pseudoaneurysm: a case report

A case of traumatic carotid-cavernous sinus fistula (CCF) associated with an intradural pseudoaneurysm is reported. A 42-year-old man developed traumatic CCF after severe head trauma. Cerebral angiography demonstrated a direct CCF associated with an intradural pseudoaneurysm at the C2 portion. Transarterial balloon embolization of the CCF caused severe subarachnoid hemorrhage. A CCF with an intradural pseudoaneurysm is life-threatening and requires emergency treatment. However, balloon occlusion in such cases is contraindicated because of possible rupture of a pseudoaneurysm. Trapping or a direct surgical approach is the treatment of choice.     

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.     

Traumatic carotid-cavernous fistula presenting subarachnoid hemorrhage 5 years after head injury; case report

A case of traumatic carotid-cavernous fistula (CCF) which presented subarachnoid hemorrhage long after the injury is reported. A 24-year-old male was admitted to the National Yokohama Hospital with complaints of severe headache and nausea. CT scan and cerebral angiography showed subarachnoid hemorrhage due to ruptured CCF. His right visual acuity has disappeared after a traffic accident 5 years before, and he had hit his forehead again 3 years previously. He experienced severe headache twice for 2 weeks after his admission. He was transferred to Kanagawa Rehabilitation Center to be treated with intravascular surgery. Plain CT showed high density areas in the basal cisterns. CT after contrast infusion disclosed a small enlarged high density area in the right cavernous sinus, and showed an enhanced mass lesion in contact with the right ventrolateral side of the midpons. The right internal carotid angiogram showed high flow CCF, fed only by the internal carotid artery. It drained mainly into the basilar plexus, partially into the basal vein of Rosenthal and the inferior petrosal sinus. The CCF was found at the C4 portion of the right internal carotid artery. CT and the angiogram revealed a part of the CCF developing into a varix in the ventral side of the prepontine cistern. It ruptured and the patient developed subarachnoid hemorrhage 5 years after the head injury. The CCF was intravascularly embolized by a detachable balloon. Early treatment for CCF is necessary to prevent the occurrence of subarachnoid hemorrhage if a part of the CCF develops into a varix.     

Transvenous embolization in spontaneous direct carotid-cavernous fistula in childhood

Carotid cavernous fistula (CCF) is an abnormal arteriovenous communication in the cavernous sinus. Direct CCF results from a tear in the intracavernous carotid artery. Typically, it has a high flow and usually presents with oculo-orbital venous congestive features such as exophthalmos, chemosis, and sometimes oculomotor or abducens cranial nerve palsy. Indirect CCF generally occurs spontaneously with subtle signs. We report a rare case of spontaneous direct CCF in childhood who did not have the usual history of craniofacial trauma or connective tissue disorder but presented with progressive chemosis and exophthalmos of the right eye. This report aims also to describe the safety and success of transvenous embolization with coils of the superior ophthalmic vein and cavernous sinus through the inferior petrosal sinus.     

A case of high flow CCF with congestive hemorrhage

The authors report a case of high flow CCF with intracerebral hemorrhage during treatment with endovascular coil embolization. A 52-year-old woman had been in good health until a sudden onset of orbital bruit and left orbital tinnitus occurred. Conjunctival chemosis and diplopia caused by left abducens palsy gradually progressed. Left internal carotid arteriography revealed a carotid-cavernous sinus fistula with direct high-flow shunt. The fistula drained into the superior orbital vein, inferior petrosal sinus, intercavernous sinus and sphenoparietal sinus with significant cortical reflux. The attempt at transarterial balloon occlusion failed. Then transvenous coil embolization was performed. During the course of endovascular treatment, follow up CT depicted intracerebral hemorrhage. Intracerebral hemorrhage was asymptomatic and thought to be caused by venous hypertension from cortical reflux. The patient underwent direct occlusion of the left sphenoparietal sinus for prevention of further hemorrhage via craniotomy. Lastly, the cavernous sinus was completely occluded by transvenous coil embolization. The signs and symptoms resolved 3 months after the procedures.     

Endovascular Treatment of Transverse-Sigmoid Sinus Dural Arteriovenous Malformations Presenting as Pulsatile Tinnitus

Transverse-sigmoid sinus dural arteriovenous malformations (DAVM) are uncommon vascular lesions for which complete cure may be difficult to obtain. A wide variety of treatments for these lesions include observation, arterial compression, surgical resection, and endovascular embolization. We propose that transverse-sigmoid sinus DAVM can be completely cured by occluding the ipsilateral dural sinus with detachable balloon and Guglielmi detachable coils (GDC) coils before arterial feeder embolization with histoacryl. Three patients who presented with pulsatile tinnitus and normal magnetic resonance imaging (MRI) studies underwent angiography, which demonstrated transverse-sigmoid sinus DAVM. All three patients wer treated with retrograde transvenous sinus embolization with complete occlusion of the transverse-sigmoid sinus with detachable balloons and GDC coils with preservation of the vein of Labbé. Subsequently, the various feeders from the external carotid artery were embolized. The tentorial arteries arising from the ipsilateral internal carotid arteries were not embolized in any of the cases, which were still contributing to the DAVM. Complete cure with thrombosis of the tentorial branch of the internal carotid artery (ICA) was seen on follow-up angiogram 1 day after embolization in one patient and on 4-week and 6-week follow-up angiograms in the other two patients. Complete occlusion of the transverse sinus proximal to the vein of Labbé, in spite of incomplete arterial feeder embolization, can result in complete cure of the transversesinus dural AVF if adequate time is given for the remaining feeders to occlude, once the fistula is obliterated.     

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.     

难治性颈动脉海绵窦瘘的原因与对策

目的 探讨难治性颈动脉海绵窦瘘（ＣＣＦ）的原因与对策。方法 对１９８６年９月至１９９８年８月间１２３例外伤性ＣＣＦ中１２例难治性ＣＣＦ进行回顾分析。结果 难治性ＣＣＦ的原因主要是：瘘口过小或过大,载瘘颈内动脉狭窄;单纯结扎颈内动脉、栓塞时球囊早脱或弹簧圈填海绵窦不够致密等早期的治疗失误;栓塞球囊早泄或移位致瘘口复发。经动脉、静脉或外科开颅等途径,用球囊、弹簧圈或（和）ＮＢＣＡ（丙烯酸正丁酯,ｎ－ｂ