1
|
Abu-Fares O, Adamou A, Lanfermann H, Krauss JK, Al-Afif S, Döring K. Pipeline flow diverter and transvenous coiling for the treatment of direct carotid cavernous sinus fistulae: a retrospective case series. CVIR Endovasc 2025; 8:44. [PMID: 40381127 DOI: 10.1186/s42155-025-00566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2025] [Accepted: 05/07/2025] [Indexed: 05/19/2025] Open
Abstract
BACKGROUND Carotid cavernous fistulae (CCF) are pathological connections between the carotid arteries and the cavernous sinus. Endovascular procedures are the mainstay treatment for CCF. The aim of this report is to evaluate the efficacy and safety of the combined use of the Pipeline Vantage (PV) flow diverter and transvenous coil embolization in the treatment of CCF. METHODS Retrospective,monocentric analysis of three patients who underwent neurointerventional treatment of clinically symptomatic CCF using a combination of transvenous coil embolization and flow diverter Implantation. Clinical data, the etiology of the CCF and clinical and radiological follow up were evaluated. RESULTS Clinical and radiological follow-up were available at 3 and 12 months. One patient experienced clinical improvement immediatley after the interventions. The other two patients improved within one year after treatment. No symptomatic complications were recorded. One year after the intervention complete CCF occulsion was documented in all cases. CONCLUSIONS We report an initial experience for the treatment of direct CCF using the combination of a new generation Pipeline FD and transvenous coil embolization. The high treatment success rate and low complication rate are encouraging.
Collapse
Affiliation(s)
- Omar Abu-Fares
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, 30625, Hannover, Germany.
| | - Antonis Adamou
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, 30625, Hannover, Germany
| | - Heinrich Lanfermann
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, 30625, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, 30625, Hannover, Germany
| | - Shadi Al-Afif
- Department of Neurosurgery, Hannover Medical School, 30625, Hannover, Germany
| | - Katja Döring
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, 30625, Hannover, Germany
| |
Collapse
|
2
|
Hirohashi A, Goto S, Imaoka E, Nishihori M, Izumi T, Muraoka S, Mizutani N, Ito S, Saito R. Management of Direct Internal Carotid-Cavernous Sinus Fistula in a Patient with Ehlers-Danlos Syndrome: A Case Study on Selective Transvenous Embolization Using Coils and N-Butyl-2-Cyanoacrylate. JOURNAL OF NEUROENDOVASCULAR THERAPY 2025; 19:2024-0121. [PMID: 40352972 PMCID: PMC12061784 DOI: 10.5797/jnet.cr.2024-0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2024] [Accepted: 04/03/2025] [Indexed: 05/14/2025]
Abstract
Objective Direct carotid-cavernous fistula (CCF) is a common neurovascular complication associated with Ehlers-Danlos syndrome (EDS). Nevertheless, reports indicate a significant incidence of treatment-related complications. Case Presentation We present a case of right CCF in a 28-year-old female with EDS. Femoral artery and vein punctures were performed under ultrasound guidance. We executed transvenous embolization (TVE) of the draining veins and the shunted fistula using a combination of coils and n-butyl-2-cyanoacrylate (NBCA), facilitated by an assisted transarterial balloon. The CCF resolved without any procedural complications. Conclusion Utilizing a combination of coils and NBCA in TVE is seen as a safe and efficient method for addressing CCF in patients with EDS. It enables preserving better visualization of the cavernous sinus and adjacent structures, making this approach particularly effective. By keeping a close watch, monitoring for potential high-risk complications, and strategically placing devices between the arterial and venous sides, the arterial puncture profile is reduced, enabling safer endovascular treatment.
Collapse
Affiliation(s)
- Akina Hirohashi
- Department of Neurosurgery, Konan Kosei Hospital, Konan, Aichi, Japan
| | - Shunsaku Goto
- Department of Neurosurgery, Konan Kosei Hospital, Konan, Aichi, Japan
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Eiki Imaoka
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shinsuke Muraoka
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Nobuhiko Mizutani
- Department of Neurosurgery, Konan Kosei Hospital, Konan, Aichi, Japan
| | - Satoshi Ito
- Department of Neurosurgery, Konan Kosei Hospital, Konan, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| |
Collapse
|
3
|
Kobayashi K, Kidani T, Nakajima S, Kanemura Y, Asai K, Izutsu N, Kawamoto S, Nishizawa N, Nomoto M, Fujimi Y, Kida M, Fujinaka T. Endovascular Treatment for Traumatic Carotid Cavernous Fistula: Case Series. JOURNAL OF NEUROENDOVASCULAR THERAPY 2025; 19:2024-0111. [PMID: 40297303 PMCID: PMC12035768 DOI: 10.5797/jnet.oa.2024-0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Accepted: 03/12/2025] [Indexed: 04/30/2025]
Abstract
Objective Traumatic carotid-cavernous fistula (TCCF) is a rare neurovascular condition that occurs after blunt head trauma. This condition accounts for approximately 4% of traumatic cerebrovascular injuries. Various symptoms can be observed in TCCF, and aggressive treatment is frequently required. Herein, we reviewed the treatment of TCCF in our hospital. Methods We retrospectively reviewed patients with TCCF between December 2021 and May 2023. The physical findings, clinical images, and surgical details of patients were investigated. Results Three men and 1 woman were included. Only 1 case was diagnosed with CCF using initial 3D-CTA; the other 3 were diagnosed after admission using DSA. All patients received endovascular treatment; 2 were initially treated with transarterial embolization, and the other 2 were treated with transvenous embolization, although 1 case of transarterial embolization required additional treatment with transvenous embolization. Complete occlusion was achieved in all cases. Two of the cases were accompanied by skull base fractures, both of which were middle fossa fractures. Conclusion TCCF is caused by direct injury to the internal carotid artery and can be accompanied by skull fractures or vessel wall damage as a result of shear force. We should suspect TCCF, especially when a skull base fracture is detected, even if the initial 3D-CTA shows no evidence of TCCF. Treatment for TCCF is mainly endovascular; however, the specific treatment approach should be determined for each case based on various factors, including vessel anatomy.
Collapse
Affiliation(s)
- Koji Kobayashi
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Tomoki Kidani
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Shin Nakajima
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Yonehiro Kanemura
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
- Department of Biomedical Research and Innovation, Institute for Clinical Research, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Katsunori Asai
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Nobuyuki Izutsu
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Saki Kawamoto
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Naoki Nishizawa
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Mikako Nomoto
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Yosuke Fujimi
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Masayoshi Kida
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, NHO Osaka National Hospital, Osaka, Osaka, Japan
| |
Collapse
|
4
|
Ayuningtyas SP, Nusanti S, Dewiputri S, Sidik M. Clinical Profiles and Treatment Outcomes of 51 Cases of Carotid Cavernous Fistula: A Retrospective Observational Study. KOREAN JOURNAL OF OPHTHALMOLOGY 2025; 39:181-188. [PMID: 40059350 PMCID: PMC12010190 DOI: 10.3341/kjo.2024.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Revised: 02/24/2025] [Accepted: 03/09/2025] [Indexed: 04/18/2025] Open
Abstract
PURPOSE This study investigated demographics, clinical profiles, imaging results, and treatment outcomes in patients with carotid cavernous fistula (CCF). METHODS This retrospective analysis examined medical records of the patients with CCF from January 2016 to January 2022. The study included 51 cases: 34 traumatic and 17 spontaneous CCFs. RESULTS A total of 51 patients with CCFs was analyzed. Traumatic CCF (34 patients, 66.7%) was more common than spontaneous CCF (17 patients, 33.3%). Traumatic CCF predominantly affected male patients, while spontaneous CCF was more frequent in female patients (p = 0.005). Clinical signs including proptosis and lagophthalmos were more common in traumatic CCF, with significant differences in eye movement restriction (p = 0.006) and bruit (p = 0.008). According to the Barrow classification, all spontaneous CCF cases were categorized as types B, C, or D, whereas traumatic CCF was predominantly classified as type A (p < 0.001). Endovascular treatment was more effective than conservative treatment in reducing clinical signs of traumatic CCF (p < 0.05), while no significant differences were observed in outcomes for spontaneous CCF between the two approaches. CONCLUSIONS Spontaneous CCF is less common than traumatic CCF in this study cohort. Traumatic and spontaneous CCF may have different clinical characteristics. Eye movement restriction and bruit are more frequently observed in traumatic CCF. After treatment for traumatic CCF, the incidence of proptosis, conjunctival abnormalities, and bruit is significantly lower in patients who undergo endovascular treatment compared to those who receive conservative management.
Collapse
Affiliation(s)
- Sita Paramita Ayuningtyas
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Syntia Nusanti
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Salmarezka Dewiputri
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Mohamad Sidik
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| |
Collapse
|
5
|
Kurban B, Mustafa S, Rehman A, Dolati P. Atypical Acute and Non-traumatic Presentation of an Indirect Carotid-Cavernous Fistula. Cureus 2025; 17:e82996. [PMID: 40416229 PMCID: PMC12103894 DOI: 10.7759/cureus.82996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2025] [Indexed: 05/27/2025] Open
Abstract
A carotid-cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus. Contrary to the typical insidious onset, we present a case of an indirect CCF in a 49-year-old woman who presented with the sudden onset of a painful, swollen, and red left eye, which was initially misdiagnosed as orbital cellulitis. It is crucial to maintain a high index of suspicion in all patients who present with the sudden onset of ocular symptoms, particularly if they exhibit pulsatile proptosis, chemosis with arterialized conjunctival veins, periorbital bruit, elevated intraocular pressure (IOP), and normal inflammatory markers. Early diagnosis is essential to prevent vision loss and other associated neurological complications. The patient underwent transvenous coil occlusion of the left cavernous sinus but later developed a recurrent fistula, underscoring the need for close follow-up after endovascular intervention to detect any residual or recurrent fistula.
Collapse
Affiliation(s)
| | - Syed Mustafa
- Department of Medical Imaging, American Hospital Dubai (AHD), Dubai, ARE
- Department of Radiology, Mediclinic Parkview Hospital, Dubai, ARE
| | - Amer Rehman
- Department of Medical Imaging, American Hospital Dubai (AHD), Dubai, ARE
| | - Parviz Dolati
- Department of Neuroscience, American Hospital Dubai (AHD), Dubai, ARE
| |
Collapse
|
6
|
Proulx-Chartier L, Parenteau È, Li J, Dallaire JS, Areal CC, Kuramochi I, Deacon C, Beaudoin AM. Seizures associated with dural arteriovenous fistulas: A systematic review of cases. Epilepsy Res 2025; 211:107531. [PMID: 40022767 DOI: 10.1016/j.eplepsyres.2025.107531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2024] [Accepted: 02/19/2025] [Indexed: 03/04/2025]
Abstract
OBJECTIVE Dural arteriovenous fistulas (DAVFs) are an unusual cause of seizures. In this systematic review, we aim to describe the clinical features, paraclinical findings, management, and prognosis of cases of DAVF-related seizures, raising awareness for a potentially treatable cause of epilepsy. METHODS This review was registered on PROSPERO (CRD42024529316). We searched OVID MEDLINE, OVID Embase, Web of Science, and Google Scholar for case reports/series of patients presenting with seizures associated with DAVFs. Original studies describing at least two out of four outcome categories (clinical features, paraclinical findings, treatment, and prognosis) were included. The methodological quality of each study was evaluated using a standardized tool. We performed descriptive analyses to summarize the clinical characteristics of all cases. We repeated these analyses while excluding cases where seizures may have had a likelier cause than DAVFs. RESULTS In total, 120 patients were included from 94 articles. Median age was 57 years, and most patients were male (70 %). The most common manifestations accompanying seizures were headaches (22 %). Status epilepticus occurred in 38 % of cases. DAVFs were most commonly in the left hemisphere. The main venous sinus involved was the transverse sinus. Cortical venous reflux was present in almost all cases (93 %); most DAVFs were considered aggressive according to Cognard and Borden classifications. Seizure freedom was most common following angiographic interventions. CONCLUSION DAVFs, even when uncomplicated, can be a potential cause of treatable seizures. More aggressive DAVFs with cortical venous reflux seem to be the main culprit. Angiographic interventions can help achieve seizure freedom.
Collapse
Affiliation(s)
- Léa Proulx-Chartier
- Faculty of Medicine, Université de Sherbrooke, 2500 Bd de l'Université, Sherbrooke, QC J1K 2R1, Canada.
| | - Ève Parenteau
- Faculty of Medicine, Université de Sherbrooke, 2500 Bd de l'Université, Sherbrooke, QC J1K 2R1, Canada.
| | - Jimmy Li
- Neurology Division, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001 12 Ave N, Sherbrooke, QC J1H 5N4, Canada; Centre de Recherche du Centre Hospitalier Universitaire de Montréal (CRCHUM), 900 rue St-Denis, Montreal, QC H2X 0A9, Canada.
| | - Jean-Simon Dallaire
- Neurology Division, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001 12 Ave N, Sherbrooke, QC J1H 5N4, Canada.
| | - Cassandra C Areal
- Neurology Division, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001 12 Ave N, Sherbrooke, QC J1H 5N4, Canada.
| | - Izumi Kuramochi
- Department of Psychiatry, Saitama Medical Centre, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan.
| | - Charles Deacon
- Neurology Division, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001 12 Ave N, Sherbrooke, QC J1H 5N4, Canada.
| | - Ann-Marie Beaudoin
- Neurology Division, Centre Hospitalier Universitaire de Sherbrooke (CHUS), 3001 12 Ave N, Sherbrooke, QC J1H 5N4, Canada.
| |
Collapse
|
7
|
Luo CB, Lee CH, Lo HY, Chang FC, Lin CJ. Onyx as an adjunctive embolic material for transvenous embolization of cavernous sinus dural arteriovenous fistula after coiling. J Chin Med Assoc 2025; 88:261-266. [PMID: 39582118 DOI: 10.1097/jcma.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2024] Open
Abstract
BACKGROUND Transvenous coil embolization (TVCE) is a common and effective treatment for cavernous sinus dural arteriovenous fistulas (CSDAVFs). However, some patients may experience residual fistulas or worsening visual symptoms after the procedure. This study aimed to compare the effectiveness of transvenous coil and Onyx embolization (TVCOE) with TVCE in treating CSDAVFs. METHODS The study included 207 patients with 222 CSDAVFs referred for TVCE, all of whom had complete angiographic follow-up over 9 years. Ninety patients (mean age, 65.3 years) with 97 CSDAVFs underwent TVCOE after coiling. Clinical data, angioarchitecture, and outcomes were retrospectively assessed and compared to 125 CSDAVFs treated with TVCE. RESULTS Key reasons for selecting TVCOE included improvement in immediate complete obliteration of CSDAVFs (n = 47, 48.5%), presence of cranial nerve palsy (n = 26, 26.8%), residual fistula with persistent pial venous reflux (n = 22, 22.7%), and redirection of fistula flow to pial venous reflux (n = 2, 2.1%). The average volume of Onyx used in TVCOE was 1.7 mL per CSDAVF. The mean coil lengths for TVCOE and TVCE were 143 and 228 cm, respectively, with a statistically significant difference ( p < 0.05). Immediate digital subtraction angiography showed complete obliteration or nearly complete obliteration of CSDAVFs in TVCOE and TVCE at rates of 97.9% and 76.8%, respectively, indicating statistical significance in immediate complete obliteration ( p < 0.05). Transient hemodynamic instability occurred in 81 (90.0%) patients due to Onyx toxicity, and one patient (1.1%) experienced hemorrhagic complications during TVCOE. CONCLUSION The use of a small volume of Onyx as an adjunctive embolic material in TVCOE resulted in reduced coil use and improved immediate complete obliteration. This technique is viable for patients with pial venous reflux. Aside from the transient hemodynamic instability, periprocedural complications and follow-up angiographic outcomes did not show significant differences between the two groups.
Collapse
Affiliation(s)
- Chao-Bao Luo
- Department of Neurosurgery, Buddhist Tzu-Chi General Hospital and Tzu-Chi University, Hualien, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Department of Radiology, Tri-Service General Hospital and National Defenses Medical Center, Taipei, Taiwan, ROC
| | - Chien-Hui Lee
- Department of Neurosurgery, Buddhist Tzu-Chi General Hospital and Tzu-Chi University, Hualien, Taiwan, ROC
| | - Hsiang-Yun Lo
- Department of Radiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| |
Collapse
|
8
|
Cervo A, Popadic B, Macera A, Rollo C, Quilici L, Valvassori L, Piano M, Sherif C, Boccardi E, Pero G. Eighteen-year journey in endovascular management of cavernous sinus DAVFs: advances, outcomes, and lessons learned. Neuroradiology 2025; 67:695-706. [PMID: 39960530 DOI: 10.1007/s00234-025-03561-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2025] [Accepted: 02/09/2025] [Indexed: 04/17/2025]
Abstract
PURPOSE This study presents a long-term single-centre experience with CS-DAVFs and discusses the historical progression, current state, and future directions of endovascular treatment. METHODS We retrospectively reviewed all patients with CS-DAVFs endovascularly treated at our institution between 2006 and 2024. We evaluated clinical presentation, imaging findings, endovascular treatment techniques, and clinical improvement. RESULTS 63 patients underwent 68 endovascular procedures. 49 patients (72%) underwent transvenous procedures through the inferior petrosal sinus or ophthalmic veins. 39 fistulas (57%) were occluded using liquid embolic agents (LEAs) alone or in combination with coils. Eight patients (12%) required the injection of LEAs in the superior pharyngeal branch of the APA to reach the complete occlusion of the fistula. In 4 cases, the vascular anatomy of the fistula required the direct puncture of the draining vein. In 46 cases (68%), the fistula was successfully occluded using coils. Complete occlusion was achieved in 52 of the cases (77%), but two cases (3%) had fistula recurrence after the first treatment. We found one complication of the endovascular procedure in the study population. The median imaging follow-up time was 12 months (range 2-135); the median clinical follow-up was 32 months (range 1.5-194). 60 Patients (95%) showed persistent clinical improvement. CONCLUSIONS Endovascular occlusion is the gold standard for CS-DAVFs, with high rates of occlusion and few complications. Continued advancements in techniques and devices are essential to improve outcomes and reduce complications.
Collapse
Affiliation(s)
- Amedeo Cervo
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Antonio Macera
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Rollo
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | | | | | | | | | - Guglielmo Pero
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| |
Collapse
|
9
|
Chu F, Li M, Li W, Wang J. Ruptured Primitive Trigeminal Artery Aneurysm Leading to Internal Carotid Artery Cavernous Sinus Fistula Intervention. J Craniofac Surg 2025:00001665-990000000-02405. [PMID: 39932795 DOI: 10.1097/scs.0000000000011098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2024] [Accepted: 12/24/2024] [Indexed: 02/13/2025] Open
Abstract
BACKGROUND Internal carotid artery cavernous sinus fistula (CCF) occurs when the cavernous segment of the internal carotid artery or its branches within the cavernous sinus rupture, creating an abnormal communication between arterial and venous blood. This leads to increased pressure within the cavernous sinus and a range of clinical manifestations. The prevalence of CCF is ~0.17% to 0.27%. Its etiology can be classified into 2 main types: traumatic, accounting for about 75% of cases, and spontaneous, accounting for the remaining 25%. The primitive trigeminal artery (PTA) is a rare remnant of the embryonic circulatory system that forms a connection between the internal carotid artery and the vertebrobasilar system. Its prevalence is estimated at 0.1% to 0.6%. A rupture of a PTA aneurysm leading to a cavernous sinus fistula of the internal carotid artery is even more uncommon. Current clinical approaches to managing this condition are still evolving and require further study. CASE REPORT A 53-year-old female patient presented with a one-month history of diplopia. Digital subtraction angiography (DSA) revealed a ruptured aneurysm of the primitive trigeminal artery, resulting in a cavernous sinus fistula of the internal carotid artery. After discussions with her family, she underwent successful interventional embolization to treat the fistula. At the 6-month follow-up, the patient's diplopia had resolved completely, and no recurrence of the cavernous sinus fistula was observed on DSA. CONCLUSION Rupture of a primitive trigeminal artery aneurysm resulting in a cavernous sinus fistula of the internal carotid artery is an exceptionally rare condition. Transarterial embolization has proven to be a feasible treatment approach; however, due to the limited number of reported cases, treatment strategies require further investigation and refinement.
Collapse
Affiliation(s)
- Fudi Chu
- School of Clinical Medicine, Shandong Second Medical University
| | - Mingjian Li
- Department of Neurosurgery, Weifang People's Hospital, Shandong Second Medical University, Weifang, Shandong, China
| | - Wei Li
- Department of Neurosurgery, Weifang People's Hospital, Shandong Second Medical University, Weifang, Shandong, China
| | - Jinpeng Wang
- Department of Neurosurgery, Weifang People's Hospital, Shandong Second Medical University, Weifang, Shandong, China
| |
Collapse
|
10
|
Koutsouras GW, Babu H, Gould G. Endonasal Endoscopic Transsphenoidal Approach to Transvenous Obliteration of Carotid-Cavernous Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2025:01787389-990000000-01469. [PMID: 39880023 DOI: 10.1227/ons.0000000000001505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Accepted: 11/04/2024] [Indexed: 01/31/2025] Open
Affiliation(s)
- George W Koutsouras
- Department of Neurosurgery, SUNY Upstate University Hospital, SUNY Upstate University Hospital, Syracuse, New York, USA
| | | | | |
Collapse
|
11
|
Mørkve SH, Wathle GK, Logallo N. Endovascular treatment of carotid-cavernous fistulas in a medium-sized Scandinavian neurovascular center. Orbit 2025:1-8. [PMID: 39831558 DOI: 10.1080/01676830.2024.2448802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Accepted: 12/20/2024] [Indexed: 01/22/2025]
Abstract
PURPOSE Carotid-cavernous fistulas (CCFs) are treated almost exclusively by endovascular techniques, but the frequency of treatments is limited in smaller centers. We analyzed all CCFs treated in our hospital to determine if high-quality treatment of CCFs can be provided in a medium-volume neurovascular center. METHODS Retrospective quality-control cohort study. RESULTS From 2005 to 2021, 28 CCF-treatments were performed in our hospital, all endovascular. Fourteen were direct and fourteen were indirect CCFs. All direct CCFs were treated using transarterial coil embolization, and in seven of these the ICA was preserved. All indirect CCFs were treated using transvenous coil embolization. Complete cure was achieved after one procedure in 24 (85.7%) patients, and in all patients (100%) after retreatments. All CCF-patients experienced significant improvement of symptoms after treatment and 79.2% were asymptomatic after 6-12 months. Two patients with direct CCFs were blind on their ipsilateral eye before treatment and remained so after treatment. Three patients had reduced vision or visual field defects ipsilateral to their indirect CCFs that normalized after treatment. One patient suffered a minor asymptomatic thromboembolic event during the treatment (3.6%), otherwise there were no complications to treatments. CONCLUSIONS High-quality treatment of CCFs can be provided in a medium-volume neurovascular center.
Collapse
Affiliation(s)
- Svein Harald Mørkve
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Gaute Kjellevold Wathle
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
12
|
Ueda K, Niimi J, Sako T, Ando K, Tasaka K, Nemoto F, Hatayama K, Naito H. Direct carotid-cavernous fistula completely treated with a small number of coils by combined transarterial and transvenous embolization: A case report. Surg Neurol Int 2025; 16:14. [PMID: 39926452 PMCID: PMC11799686 DOI: 10.25259/sni_950_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Accepted: 12/19/2024] [Indexed: 02/11/2025] Open
Abstract
Background Endovascular treatment options for direct carotid-cavernous fistula (CCF) include transarterial or transvenous embolization with detachable coils and balloons, parent artery occlusion, or the use of flow-diverting stents across the fistula. Although combined transarterial and transvenous embolization is uncommon, it can be advantageous. We present a case of direct CCF treated successfully with a combined approach using a minimal number of detachable coils. Case Description A 33-year-old female presented with tinnitus and headache following cesarean delivery and was transferred to our hospital. Cerebral angiography revealed a high-flow shunt from the superior lateral wall of the left cavernous internal carotid artery directly into the cavernous sinus, with a 3.5 × 2.8 mm shunted pouch. A diagnosis of direct CCF was confirmed. To maximize the packing density within the shunted pouch and to manage various situations during embolization, a combined transarterial and transvenous approach was utilized. Complete obliteration of the shunt was achieved without complications using only four detachable coils. The patient was discharged on postoperative day 3 with a modified Rankin Scale score of 0, and there has been no recurrence during the 6-month follow-up. Conclusion Direct CCF cases are relatively rare and complex to treat. This case illustrates practical strategies and considerations for achieving complete shunt obliteration with minimal intervention, highlighting the effectiveness of combined transarterial and transvenous embolization.
Collapse
Affiliation(s)
- Kotaro Ueda
- Department of Neurosurgery, Funabashi Municipal Medical Center, Funabashi City, Japan
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Kranawetter B, Cho A, Hirschmann D, Göbl P, Dorfer C, Rössler K, Dodier P, Wang WT, Gatterbauer B, Gruber A, Kitz K, Frischer JM. Radiosurgery as a Stand-Alone Treatment Option for Cerebral Dural Arteriovenous Fistulas: The Vienna Series. J Neurol Surg A Cent Eur Neurosurg 2025; 86:48-55. [PMID: 38151030 DOI: 10.1055/a-2235-5256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
BACKGROUND Gamma Knife radiosurgery (GKRS) has been demonstrated to be an effective and safe treatment method for dural arteriovenous fistulas (DAVFs). However, only few studies, mostly with limited patient numbers, have evaluated radiosurgery as a sole and upfront treatment option for DAVFs. METHODS Thirty-three DAVF patients treated with GKRS as a stand-alone management at our institution between January 1992 and January 2020 were included in this study. Obliteration rates, time to obliteration, neurologic outcome, and complications were evaluated retrospectively. RESULTS Complete overall obliteration was achieved in 20/28 (71%) patients. The postradiosurgery actuarial rates of obliteration at 2, 5, and 10 years were 53, 71, and 85%, respectively. No difference in time to obliteration between carotid-cavernous fistulas (CCFs; 14/28, 50%, 17 months; 95% confidence interval [CI]: 7.4-27.2) and non-CCFs (NCCFs; 14/28, 50%, 37 months; 95% CI: 34.7-38.5; p = 0.111) were found. Overall, the neurologic outcome in our series was highly favorable at the time of the last follow-up. A complete resolution of symptoms was seen in two-thirds (20/30, 67%) of patients. One patient with multiple DAVFs suffered from an intracranial hemorrhage of the untreated lesion and died during the follow-up period, resulting in a yearly bleeding risk of 0.5%. No complications after radiosurgery were observed in our series. CONCLUSION Our results show that GKRS is a safe and effective stand-alone management option for selected DAVF patients.
Collapse
Affiliation(s)
- Beate Kranawetter
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Anna Cho
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Dorian Hirschmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Göbl
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | | | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital Linz, Linz, Austria
| | - Klaus Kitz
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Josa M Frischer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
14
|
Liao WJ, Hsiao CY, Chen CH, Tseng YY, Yang TC. Spontaneous Resolution of an Aggressive Direct Carotid Cavernous Fistula Following Partial Transvenous Embolization Treatment: A Case Report and Review of Literatures. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:2011. [PMID: 39768891 PMCID: PMC11728099 DOI: 10.3390/medicina60122011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2024] [Revised: 11/28/2024] [Accepted: 12/02/2024] [Indexed: 01/16/2025]
Abstract
Traumatic direct type carotid cavernous fistula (CCF) is an acquired arteriovenous shunt between the carotid artery and the cavernous sinus post severe craniofacial trauma or iatrogenic injury. We reported a 46-year-old woman who had developed a traumatic direct type CCF after severe head trauma with a skull base fracture and brain contusion hemorrhage. The clinical manifestations of the patient included pulsatile exophthalmos, proptosis, bruits, chemosis, and a decline in consciousness. Magnetic resonance imaging (MRI) revealed engorgement of the right superior ophthalmic vein (SOV), perifocal cerebral edema in the right frontal-temporal cortex, right basal ganglia, and brain stem. Digital subtraction angiography (DSA) disclosed a direct type high-flow CCF with an aggressive cortical venous reflux drainage pattern, which was attributed to Barrow type A and Thomas classification type 5. After partial treatment by transvenous coil embolization for the CCF, the residual high-flow fistula with aggressive venous drainage had an unusual rapid spontaneous resolution in a brief period. Therefore, it is strongly recommended to meticulously monitor the clinical conditions of patients and perform brain MRI and DSA at short intervals to determine the treatment strategy for residual CCF after partial endovascular treatment.
Collapse
Affiliation(s)
- Wen-Jui Liao
- Department of Neurosurgery, Chung Shan Medical University Hospital, Taichung City 402, Taiwan, China; (W.-J.L.); (C.-H.C.)
| | - Chun-Yuan Hsiao
- Department of Medical Education, Chung Shan Medical University Hospital, Taichung City 402, Taiwan, China;
| | - Chin-Hsiu Chen
- Department of Neurosurgery, Chung Shan Medical University Hospital, Taichung City 402, Taiwan, China; (W.-J.L.); (C.-H.C.)
| | - Yuan-Yun Tseng
- Department of Neurosurgery, New Taipei Municipal Tu-Cheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City 236, Taiwan, China;
| | - Tao-Chieh Yang
- Department of Neurosurgery, Chung Shan Medical University Hospital, Taichung City 402, Taiwan, China; (W.-J.L.); (C.-H.C.)
- School of Medicine, Chung Shan Medical University, Taichung City 402, Taiwan, China
| |
Collapse
|
15
|
Crowe JR, Regenhardt RW, Dmytriw AA, Vranic JE, Stapleton CJ, Patel AB. Deconstructive repair of a direct carotid-cavernous fistula via a posterior circulation retrograde approach. J Cerebrovasc Endovasc Neurosurg 2024; 26:394-398. [PMID: 38523550 PMCID: PMC11695501 DOI: 10.7461/jcen.2024.e2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 01/19/2024] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
We report a case of a 24-year-old patient who presented after a head trauma with a traumatic occlusion of his left internal carotid artery. He underwent diagnostic cerebral angiogram and was found to have a direct left carotid-cavernous fistula (CCF) with retrograde filling from the posterior circulation across the posterior communicating artery. Because of the severe injury to the left internal carotid artery (ICA), reconstructive repair of the ICA was not possible. The patient underwent deconstructive repair of the CCF by coil embolization using a posterior retrograde approach. Coils were successfully placed in the cavernous sinus and back into the left ICA with complete cure of the CCF and restoration of cerebral perfusion distal to the treated CCF. We review the types of CCFs, their clinical presentation, and their endovascular treatments. Retrograde access of a direct CCF is rarely reported in the literature, and we believe this approach offers a viable alternative in appropriately selected patients.
Collapse
Affiliation(s)
- Jonathan R. Crowe
- Massachusetts General Hospital, Department of Neurology, 55 Fruit Street, Boston, MA
- Brigham and Women’s Hospital, Department of Neurology, 75 Francis Street, Boston, MA
| | - Robert W. Regenhardt
- Massachusetts General Hospital, Department of Neurology, 55 Fruit Street, Boston, MA
| | - Adam A. Dmytriw
- Massachusetts General Hospital, Department of Neurology, 55 Fruit Street, Boston, MA
| | - Justin E. Vranic
- Massachusetts General Hospital, Department of Neurology, 55 Fruit Street, Boston, MA
| | | | - Aman B. Patel
- Massachusetts General Hospital, Department of Neurology, 55 Fruit Street, Boston, MA
| |
Collapse
|
16
|
Abramyan A, Gupta G, Sreenivasan S, Lowenthal J, Samaan M, Khandelwal P, Sundararajan S, Sun H, Nourollah-Zadeh E, Roychowdhury S. Stand-alone transarterial flow diversion for treatment of carotid cavernous fistulas. J Stroke Cerebrovasc Dis 2024; 33:108047. [PMID: 39424211 DOI: 10.1016/j.jstrokecerebrovasdis.2024.108047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 09/26/2024] [Accepted: 09/27/2024] [Indexed: 10/21/2024] Open
Abstract
OBJECTIVE Carotid-cavernous fistulas (CCFs) are rare arteriovenous communications allowing blood to flow from the carotid artery into the cavernous sinus. Although currently coil and/or liquid embolization remain the preferred treatment methods for CCFs, flow diverters (FD) stents represent a viable alternative to traditional embolization techniques. This study explores both the technical aspects and rationale behind using FD stents as a stand-alone treatment approach for CCFs. METHODS The study includes records of 7 patients with CCFs treated at two comprehensive stroke centers from 2019 to 2023. Patients treated with FD stenting in conjunction with coil and/or liquid embolization were excluded from the study. RESULTS Five patients were diagnosed with direct CCFs and 2 patients with indirect CCFs. Six patients were treated with the Surpass Evolve FD stent and 1 patient with the Pipeline FD stent. DSA follow-up was performed for an average duration of 14.4 months following FD placement. Complete fistula obliteration with no residual shunting was observed in all patients. Furthermore, all patients experienced a complete resolution of symptoms following treatment. CONCLUSIONS The authors' experiences suggest the efficacy and safety of FD stenting as a stand-alone treatment option for CCFs. Compared to embolization, FD stents can better preserve the parent vessel and promote healing with less associated mass effect. Despite being a retrospective self-assessment with a relatively small sample size, to the authors' knowledge, this study represents the largest individual case series of patients with CCF treated with stand-alone FD stenting.
Collapse
Affiliation(s)
- Arevik Abramyan
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Jersey, USA.
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Jersey, USA.
| | - Sanjeev Sreenivasan
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Jersey, USA.
| | - Jonathan Lowenthal
- Department of Interventional Radiology, University Radiology, Robert Wood Johnson Medical School, New Jersey, USA.
| | - Mena Samaan
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Jersey, USA.
| | - Priyank Khandelwal
- Department of Neurology, Robert Wood Johnson Medical School, RUTGERS University, New Jersey, USA.
| | - Srihari Sundararajan
- Department of Interventional Radiology, University Radiology, Robert Wood Johnson Medical School, New Jersey, USA.
| | - Hai Sun
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Jersey, USA.
| | - Emad Nourollah-Zadeh
- Department of Neurology, Robert Wood Johnson Medical School, RUTGERS University, New Jersey, USA.
| | - Sudipta Roychowdhury
- Department of Interventional Radiology, University Radiology, Robert Wood Johnson Medical School, New Jersey, USA.
| |
Collapse
|
17
|
Jain R, Jagdhane N, Deshmukh S, Priola SM, Chavda V, Chaurasia B. A "Mismatched" connection: a rare case of indirect or dural carotid-cavernous fistula: a case based review. Ann Med Surg (Lond) 2024; 86:7368-7376. [PMID: 39649866 PMCID: PMC11623852 DOI: 10.1097/ms9.0000000000002669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 10/05/2024] [Indexed: 12/11/2024] Open
Abstract
Introduction and importance A carotid-cavernous sinus fistula is an abnormal connection between the internal or external carotid artery and the venous system of the cavernous sinus. It represents a rare entity, and it is often misdiagnosed due to its overlapping symptoms with other conditions such as cavernous sinus thrombosis or orbital inflammation. Cerebral angiography continues to be the gold standard for diagnosis and surgical planning in patients with CCF, and the endovascular trans-venous approach still represents the primary line of treatment. Trans-arterial technique has become an excellent treatment option since the advent of embolic agents. Case presentation Here, the authors report the case of a 42-year-old male with a one-week history of impaired visual acuity, bilateral eye edema, eye redness, and ophthalmoplegia. A neuro-ophthalmological examination found proptosis, conjunctival chemosis, and sclera injection. Examination using MR venography and digital subtraction angiography (DSA) revealed an abnormal connection between the meningeal branch of the ICA, the ECA, and the cavernous sinus. The patient received endovascular treatment with Onyx injection into the facial vein with thrombosis of the anterior cavernous sinus. The patient presented an uneventful postoperative period and was symptoms-free on postoperative day 1. Clinical discussion CCF are rare and challenging conditions that require a multidisciplinary approach. Conclusion The endovascular treatment represents the gold standard and usually allows an effective interruption of the abnormal vascular connection with an almost immediate resolution of the preoperative signs and symptoms.
Collapse
Affiliation(s)
- Ruchit Jain
- Department of Surgery, Government Medical College, Miraj
| | - Nitin Jagdhane
- Department of Neurosurgery, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India
| | - Sameer Deshmukh
- Dr. Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India
| | - Stefano M. Priola
- Division of Neurosurgery, Health Sciences North, Northern Ontario School of Medicine University, Sudbury (ON), Canada
| | - Vishal Chavda
- Department of Pathology, Stanford school of Medicine, Stanford, CA, USA
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
| |
Collapse
|
18
|
Sharkey B, Kosco E, Waack A, Lucarelli V, Gabel BC. Carotid Cavernous Fistula and Its Association With Spine Surgery: A Case Report. Cureus 2024; 16:e75160. [PMID: 39759693 PMCID: PMC11699881 DOI: 10.7759/cureus.75160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2024] [Indexed: 01/07/2025] Open
Abstract
A carotid cavernous fistula (CCF) is a disruption in the carotid arteries within the cavernous sinus. The pooling of blood in the sinus causes a myriad of neurological deficits. When correctly diagnosed, this condition can be easily managed through surgical intervention. However, its rareness and similarity in presentation to other neurological conditions allow for misdiagnosis and subsequent progression to permanent disability. Therefore, it is imperative to understand the unique clinical features and signs of CCFs. We report on the clinical workup, diagnosis, and treatment of the first documented case of a patient who developed a carotid cavernous fistula in conjunction with spine surgery.
Collapse
Affiliation(s)
- Brandon Sharkey
- Division of Neurosurgery, The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Ethan Kosco
- Division of Neurosurgery, The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Andrew Waack
- Division of Neurosurgery, Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Vito Lucarelli
- Division of Neurosurgery, The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Brandon C Gabel
- Department of Neurosurgery, ProMedica Toledo Hospital, Toledo, USA
| |
Collapse
|
19
|
Madapoosi A, Sanchez-Forteza A, Mrad TA, McGuire LS, Theiss P, Tshibangu M, Charbel F, Alaraj A. Part 1: Pushing the boundaries of neurointerventional surgery: A historical review of the work of Dr Gerard Debrun. Interv Neuroradiol 2024; 30:854-861. [PMID: 39113496 PMCID: PMC11569736 DOI: 10.1177/15910199241272519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 11/19/2024] Open
Abstract
French-American neurointerventionalist and pioneer, Dr Gerard Debrun, laid the groundwork for treatments which have become irreplaceable in neurointerventional surgery today. This article aims to outline the career of Dr Debrun while highlighting his accomplishments and contributions to the field of neurointerventional surgery. We selected relevant articles from PubMed authored or co-authored by Dr Debrun between 1941 and 2023. All included articles discuss the accomplishments and contributions of Dr Debrun. Dr Debrun began his career in France by investigating neurointerventional techniques, most notably the intravascular Detachable Balloon Catheter (DBC). His work was recognized by renowned neurosurgeon Dr Charles Drake, who recruited him to London, Ontario. Dr Debrun created the foundation for homemade manufacturing of DBCs, building on one of the largest series for use of DBCs in cerebrovascular disease. Dr Debrun spent time as faculty at Massachusetts General Hospital (MGH) and Johns Hopkins Hospital, before arriving at the University of Illinois Chicago (UIC) where he remained until his retirement. Dr Debrun's subsequent contributions included the calibrated-leak balloon catheter, pioneering of glue embolization, setting the foundation for preoperative AVM embolizations, and as an early adopter of the Guglielmi detachable coil (GDC), including mastering the balloon remodeling technique for wide neck aneurysms. Dr Debrun established the first integrated neurointerventional surgery program at UIC, establishing a well sought-after fellowship program. Dr Debrun lectured extensively and was a prolific writer on neurointerventional surgery throughout this career. His contributions established the foundation for several techniques which have since become standard practice in present-day neurointerventional surgery.
Collapse
Affiliation(s)
- Adrusht Madapoosi
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | | | - Tatiana Abou Mrad
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Laura Stone McGuire
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Peter Theiss
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Mpuekela Tshibangu
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Fady Charbel
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| |
Collapse
|
20
|
Tandean S, Harsan H, Siahaan AMP, Septian H, Josethang A. Delayed Pontomesencephalic and Cervical Cord Venous Drainage Followed by Contralateral Carotid-Cavernous Fistula after Craniofacial Fractures: A Case Report. Neurointervention 2024; 19:185-189. [PMID: 39390950 PMCID: PMC11540479 DOI: 10.5469/neuroint.2024.00318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 09/21/2024] [Accepted: 09/23/2024] [Indexed: 10/12/2024] Open
Abstract
A 24-year-old male was admitted with progressive cervical hypesthesia, tetraparesis, dyspnea, and a history of craniofacial fracture. Spinal magnetic resonance imaging (MRI) showed brainstem edema extending to the thoracic spine with multiple prominent perimedullary vascular structures. Cerebral digital-substraction angiography revealed Barrow type A carotid-cavernous fistula. Total occlusion with preservation of internal carotid artery flow was achieved using 1 detachable balloon and 6 coils. Postoperatively, immediate respiratory recovery, gradual extremities strength improvement, and right abducens nerve palsy were found. One month follow-up cervical MRI showed good recovery of spinal cord edema and perimedullary veins.
Collapse
Affiliation(s)
- Steven Tandean
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
- Department of Neurosurgery, Siloam Dhirga Surya Hospital, Medan, Indonesia
| | - Harsan Harsan
- Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
| | - Andre Marolop Pangihutan Siahaan
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
- Department of Neurosurgery, Siloam Dhirga Surya Hospital, Medan, Indonesia
| | - Harley Septian
- Department of Radiology, Siloam Dhirga Surya Hospital, Medan, Indonesia
| | | |
Collapse
|
21
|
Mohammad Razali A, Sobri MJ, Fuad MKA, Abdul Rashid AM, Md Noh MSF. Complex Indirect Carotid-Cavernous Fistula With Contralateral Ophthalmic Manifestations. Cureus 2024; 16:e73670. [PMID: 39677153 PMCID: PMC11645732 DOI: 10.7759/cureus.73670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2024] [Indexed: 12/17/2024] Open
Abstract
A carotid-cavernous fistula (CCF) involves an abnormal communication between the carotid artery and the cavernous sinus. For indirect CCF, it usually occurs in post-menopausal women. Contralateral symptoms for indirect CCF are rare. We report a 79-year-old lady with underlying hypertension and dyslipidemia, who had a complex indirect CCF from the right internal and right external carotid artery, draining into the left ophthalmic vein and giving rise to left ocular manifestation. Endovascular embolization was attempted but was unsuccessful. The patient subsequently developed a stroke one day post-procedure, with a favorable recovery of function.
Collapse
Affiliation(s)
- Amirah Mohammad Razali
- Ophthalmology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, MYS
| | - Mohammad Jazli Sobri
- Ophthalmology, Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, Serdang, MYS
| | | | | | | |
Collapse
|
22
|
Panameño OA, Morales J. The Treatment of Indirect Carotid Cavernous Fistula in a Pediatric Patient With Deep Recurrent Ophthalmic Artery and Hemophilia. Cureus 2024; 16:e73803. [PMID: 39687823 PMCID: PMC11648339 DOI: 10.7759/cureus.73803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2024] [Indexed: 12/18/2024] Open
Abstract
The treatment of indirect carotid-cavernous fistula (CCF) poses a unique challenge. Currently, endovascular interventions remain the principal treatment option with high cure rates and acceptable safety profiles. The anatomical characteristics of individual cases determine the optimal vascular access routes (transvenous vs. transarterial), and the devices utilized to achieve therapeutic goals. We present a rare case of an indirect CCF in a 13-year-old patient with an anatomical variant of the ophthalmic artery and hemophilia. CCFs are infrequent in the pediatric population, and an association with a deep recurrent ophthalmic artery (DROA) and hemophilia presents a unique treatment challenge. The patient had been diagnosed with type A hemophilia in 2013. In November 2022, he had presented with insidious conjunctival hyperemia and developed gradual ocular proptosis. He had been referred to Ophthalmology in October 2023, with mild symptoms and no ocular bruit or visual acuity deterioration. Angio CT, angio MRI, and cerebral angiography at that time had shown an indirect CCF. The association of an anatomical variant with the indirect CCF led to adverse anatomy and failed transvenous/transarterial vascular access. Classic treatment options (coils, detachable balloons, and liquid embolic agents) are not feasible when selective microcatheterism is unsuccessful. A FRED flow diverter was placed in the cavernous segment of the internal carotid artery (ICA) as an off-label solution to adverse patient vascular anatomy. Successful device implantation resulted in the gradual resolution of the patient's ocular symptoms.
Collapse
Affiliation(s)
- Oscar A Panameño
- Neurological Surgery, Hospital Jose Eleuterio Gonzalez, Universidad de Nuevo Leon, Monterrey, MEX
| | - Jesus Morales
- Neurological Surgery, Hospital Jose Eleuterio Gonzalez, Universidad de Nuevo Leon, Monterrey, MEX
| |
Collapse
|
23
|
Zhu D, Yu Z, Zhang W, Zhang S. Experience in the diagnosis and treatment of non-invasive bilateral carotid cavernous sinus fistula based on CT image examination. SLAS Technol 2024; 29:100191. [PMID: 39293642 DOI: 10.1016/j.slast.2024.100191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 07/20/2024] [Accepted: 09/15/2024] [Indexed: 09/20/2024]
Abstract
Carotid cavernous fistula is a rare but clinically important vascular abnormality that is challenging to diagnose and treat. The clinical data of a patient with bilateral carotid cavernous fistula diagnosed by CT images were retrospectively analyzed. Through the analysis of CT images, the patient was accurately located and the diagnosis was confirmed. CT images can provide detailed anatomical information and accurately show the location, morphology and hemodynamic characteristics of carotid cavernous fistula. Through CT image examination, we successfully diagnosed bilateral carotid cavernous fistula patients, and can provide an important reference for surgical treatment. Therefore, CT image examination can provide accurate diagnosis and surgical planning information, and provide support for the formulation of individual treatment plans for patients. The application of this method is helpful to improve the early diagnosis rate and treatment effect of carotid cavernous fistula.
Collapse
Affiliation(s)
- Dan Zhu
- Department of Neurology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Hainan 570311, China.
| | - Zhenyang Yu
- Department of Neurology, Shenzhen Longgang Central Hospital, Shenzhen 518100, China
| | - Weiguang Zhang
- Department of Neurosurgery, the Forth Affiliated Hospital of Harbin Medical University, Heilongjiang 150086, China
| | - Shuai Zhang
- Department of Neurology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Hainan 570311, China
| |
Collapse
|
24
|
Thrishulamurthy CJ, Ahmed HS, Pendharkar H, Kusuma MJ. Evisceration and ocular prosthetic implantation following endovascular coiling for the management of endophthalmitis in a long-standing post-traumatic unilateral carotid-cavernous fistula: A case report and review of the literature. Oman J Ophthalmol 2024; 17:388-392. [PMID: 39651520 PMCID: PMC11620303 DOI: 10.4103/ojo.ojo_41_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/15/2024] [Indexed: 12/11/2024] Open
Abstract
Carotid-cavernous fistula (CCF) is a rare condition involving an abnormal communication between the carotid artery and the cavernous sinus. We present a unique case of posttraumatic unilateral CCF initially misdiagnosed as a corneal melt with iris prolapse and orbital cellulitis. The patient, a 25-year-old male, experienced swelling, bleeding, and sudden vision loss in the affected eye following a fall. Imaging confirmed a direct CCF, and the patient underwent endovascular coiling, evisceration, and prosthetic replacement. Partial loss of levator palpebrae superioris muscle function was observed postprocedure. This case underscores the diagnostic challenge of CCF and highlights the significance of early and accurate diagnosis for appropriate management.
Collapse
Affiliation(s)
- Chinmayee J. Thrishulamurthy
- Department of Ophthalmology, Minto Ophthalmic Hospital, Regional Institute of Ophthalmology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - H. Shafeeq Ahmed
- Department of Ophthalmology, Minto Ophthalmic Hospital, Regional Institute of Ophthalmology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Hima Pendharkar
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - M. J. Kusuma
- Department of Ophthalmology, Minto Ophthalmic Hospital, Regional Institute of Ophthalmology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| |
Collapse
|
25
|
Namitha VG, Neena R, Jayadevan ER. Carotid-cavernous fistula due to contralateral orbital trauma. Oman J Ophthalmol 2024; 17:384-387. [PMID: 39651519 PMCID: PMC11620318 DOI: 10.4103/ojo.ojo_258_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/10/2023] [Accepted: 07/09/2024] [Indexed: 12/11/2024] Open
Abstract
Direct carotid cavernous fistula is an abnormal arterio-venous connection from the carotid artery to the cavernous sinus (CS), resulting in high-pressure arterial blood entering the low-pressure venous CS. Most often, it occurs posttrauma and presents with ipsilateral orbital signs. In this report, we describe the case of a 54-year-old man, who presented with a late-onset right-sided red eye and diplopia following contralateral (left sided) orbital trauma (road traffic accident 7 months ago). Ocular examination revealed signs of Lateral rectus palsy, axial proptosis, and elevated intraocular pressure with dilated episcleral vessels in the right eye. Clinical findings were consistent with the diagnosis of right-sided direct CCF. To our surprise, digital subtraction angiogram revealed a left CCF with prominence of signs on the contralateral side. He underwent near-total endovascular coiling of the fistula, with initial aggravation of symptoms followed by near-total resolution.
Collapse
Affiliation(s)
- V. G. Namitha
- Department of Paediatric Ophthalmology, Strabismus and Neurophthalmology, Giridhar Eye Institute, Kochi, Kerala, India
| | - R. Neena
- Department of Paediatric Ophthalmology, Strabismus and Neurophthalmology, Giridhar Eye Institute, Kochi, Kerala, India
| | - E. R. Jayadevan
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| |
Collapse
|
26
|
Ribeiro M, Oliveira J, Meira J, Soares-Dos-Reis R, Silva ML, Albuquerque L, Falcão-Reis F, Barbosa-Breda J. When a Red Eye Is a Red Flag: A Nontraumatic Case of a Direct Carotid-Cavernous Fistula. J Neuroophthalmol 2024; 44:e311-e313. [PMID: 37078899 DOI: 10.1097/wno.0000000000001847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Affiliation(s)
- Margarida Ribeiro
- Department of Ophthalmology (MR, JO, JM, FF-R, JB-B), Centro Hospitalar e Universitário de São João, Porto, Portugal; Department of Biomedicine (MR), Unit of Pharmacology and Therapeutics, Faculty of Medicine of Porto University, Porto, Portugal; Department of Neurology (RS-d-R), Centro Hospitalar e Universitário de São João, Porto, Portugal; Department of Clinical Neurosciences and Mental Health (RS-d-R), Faculty of Medicine, University of Porto, Porto, Portugal; Department of Neuroradiology (MLS, LA), Centro Hospitalar e Universitário de São João, Porto, Portugal; Department of Surgery and Physiology (FF-R), Faculty of Medicine of Porto University, Porto, Portugal; UnIC@RISE (JB-B), Department of Surgery and Physiology, Faculty of Medicine of Porto University, Porto, Portugal; and KU Leuven (JB-B), Research Group Ophthalmology, Department of Neurosciences, Leuven, Belgium
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Viola V, Faini C, Bortolotti C, Guarino M, Cirillo L, Rinaldi R. Transient fourth nerve palsy preceding cervical myelopathy due to carotid-cavernous fistula. BMJ Case Rep 2024; 17:e260333. [PMID: 39159980 DOI: 10.1136/bcr-2024-260333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/21/2024] Open
Abstract
Carotid-cavernous fistulas (CCFs) are rare intracranial vascular malformations. Among the various classifications available, the most recently proposed highlights the strong correlation between venous drainage pattern and clinical presentation. We present the case of a woman in her 70s with a history of transient palsy of the fourth cranial nerve who presented with subacute cervical myelopathy, which was caused by a CCF with venous drainage into the peribulbar and perimedullary plexus.Given this atypical presentation of CCF and the diagnostic challenges it poses, we conducted a comprehensive PubMed search looking for CCFs presenting with cervical myelopathy and our results confirmed their rarity and allowed us to identify clinical elements that may help clinicians diagnose and manage this potentially treatable condition.
Collapse
Affiliation(s)
- Veronica Viola
- DIBINEM - Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Claudia Faini
- DIBINEM - Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Carlo Bortolotti
- UOC Neurochirurgia, IRCSS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Maria Guarino
- UOC Clinica Neurologica - Rete Neurologica Metropolitana (NEUROMET), Policlinico Sant'Orsola- Malpighi, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luigi Cirillo
- DIBINEM - Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
- Unità di Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Rita Rinaldi
- UOC Clinica Neurologica - Rete Neurologica Metropolitana (NEUROMET), Policlinico Sant'Orsola- Malpighi, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| |
Collapse
|
28
|
Harake ES, Nieblas-Bedolla E, Wilseck Z, Chaudhary N, Armonda RA, Pandey AS, Dowlati E. Endovascular approaches for the treatment of dural carotid-cavernous fistulas: A systematic review. Interv Neuroradiol 2024:15910199241272595. [PMID: 39113637 PMCID: PMC11571140 DOI: 10.1177/15910199241272595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/15/2024] [Indexed: 11/20/2024] Open
Abstract
INTRODUCTION Dural carotid-cavernous fistulas (dCCFs), also known as indirect carotid-cavernous fistulas, represent abnormal connections between the arterial and venous systems within the cavernous sinus that are typically treated via endovascular approach. We aim to investigate the clinical characteristics of patients with dCCFs based on the endovascular treatment approach and assess angiographic and clinical outcomes. METHODS A systematic review of the literature was performed. Data including number of patients, demographics, presenting clinical symptoms, etiology of fistula, Barrow classification, and embolization material were collected and evaluated. Outcome measures collected included degree of fistula occlusion, postoperative symptoms, complications, and mean follow-up time. RESULTS A total of 52 studies were included examining four primary endovascular approaches for treating dCCFs: transarterial, transfemoral-transvenous (transpetrosal or other), transorbital (percutaneous or via cutdown), and direct transfacial access. Overall data was collected from 736 patients with 817 dCCFs. Transarterial approaches exhibit lower dCCF occlusion rates (75.6%) compared to transvenous techniques via the inferior petrosal sinus (88.1%). The transorbital approach via direct puncture or surgical cutdown offers a more direct path to the cavernous sinus, although with greater complications including risk of orbital hematoma. The direct transfacial vein approach, though limited, shows up to 100% occlusion rates and minimal complications. CONCLUSION We provide a comprehensive review of four main endovascular approaches for dCCFs. In summary, available endovascular treatment options for dCCFs have expanded and provide effective solutions with generally favorable outcomes. While the choice of approach depends on individual patient factors and technique availability, traditional transvenous procedures have emerged as the first-line endovascular treatment. There is growing, favorable literature on direct transorbital and transfacial approaches; however, more studies directly comparing these general transvenous options are necessary to refine treatment strategies.
Collapse
Affiliation(s)
- Edward S Harake
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Zachary Wilseck
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
29
|
Madapoosi A, Sanchez-Forteza A, Mrad TA, McGuire LS, Theiss P, Tshibangu M, Charbel F, Alaraj A. Part 2: The development and advancement of the detachable balloon catheter; a historical and technical review. Interv Neuroradiol 2024:15910199241272531. [PMID: 39109631 PMCID: PMC11571430 DOI: 10.1177/15910199241272531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 11/20/2024] Open
Abstract
The detachable balloon catheter (DBC) was a revolutionary technique for the treatment of cerebrovascular pathologies. It was used to treat carotid cavernous fistulas (CCFs), vertebro-jugular fistulas, arteriovenous malformations (AVMs), and aneurysms. The DBC became the foundation for neurointerventional techniques, leading to the development of coil embolization and bioactives. Our team selected relevant articles from PubMed published between 1974 and 2023. Articles were excluded if they did not discuss the use or development of the detachable balloon catheter or subsequent technologies. The DBC was used to occlude vessels, either temporarily or permanently. Dr Gerard Debrun implemented findings from Dr Fedor Serbinenko's research to develop an intravascular detachable balloon technique. He developed many variations using type I and type II balloon catheters that differed in size, length, and material, allowing for the personalization of treatment based on the lesion. This revolutionary thinking showed that every pathology has a different shape and anatomy that require a unique approach. The DBC would offer the first alternative to the conventional practice of carotid occlusion in CCF treatment at the time. The DBC would later be used in aneurysm occlusion and the embolization of AVMs, with additional benefit in traumatic vascular sacrifice. Although the DBC has largely been replaced, it is still useful in a small subset of patients, and has financial incentive as it is more affordable than coils. This technique was a monumental stride in the history of neurointervention and helped propel the specialty to the current era of patient-specific interventions.
Collapse
Affiliation(s)
- Adrusht Madapoosi
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | | | - Tatiana Abou Mrad
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Laura Stone McGuire
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Peter Theiss
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Mpuekela Tshibangu
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Fady Charbel
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| |
Collapse
|
30
|
Bai J, Ismail R, Kessler A, Kawakyu-O'Connor D. Imaging of cerebrovascular complications from blunt skull base trauma. Emerg Radiol 2024; 31:529-542. [PMID: 38806851 PMCID: PMC11289000 DOI: 10.1007/s10140-024-02243-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/13/2024] [Indexed: 05/30/2024]
Abstract
Cerebrovascular complications from blunt trauma to the skull base, though rare, can lead to potentially devastating outcomes, emphasizing the importance of timely diagnosis and management. Due to the insidious clinical presentation, subtle nature of imaging findings, and complex anatomy of the skull base, diagnosing cerebrovascular injuries and their complications poses considerable challenges. This article offers a comprehensive review of skull base anatomy and pathophysiology pertinent to recognizing cerebrovascular injuries and their complications, up-to-date screening criteria and imaging techniques for assessing these injuries, and a case-based review of the spectrum of cerebrovascular complications arising from skull base trauma. This review will enhance understanding of cerebrovascular injuries and their complications from blunt skull base trauma to facilitate diagnosis and timely treatment.
Collapse
Affiliation(s)
- James Bai
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 648, 14642, Rochester, NY, USA.
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | | |
Collapse
|
31
|
Chen SW, Lee CH. Direct carotid-cavernous fistula after functional endoscopic sinus surgery - A case report. Int J Surg Case Rep 2024; 121:110013. [PMID: 39024994 DOI: 10.1016/j.ijscr.2024.110013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/29/2024] [Accepted: 07/04/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Direct carotid-cavernous fistulas (CCF) are primarily caused by head trauma. Some cases have also been attributed to iatrogenic injuries during endovascular procedures. However, the reports of functional endoscopic sinus surgery (FESS) associated with direct CCFs are extremely rare. PRESENTATION OF CASE A 52-year-old male worker, who suffered from chronic sinusitis and underwent functional endoscopic sinus surgery (FESS) performed by an otolaryngologist. Intra-operative finding indicated a left sphenoid sinus wall injury without internal carotid artery bleeding, which was repaired using mucosa and tissue glue. One month after discharge, he began experiencing tinnitus, headache and swelling in his left eye. Cerebral angiography revealed a direct carotid-cavernous fistula (CCF) on the left side. The patient underwent transarterial and transvenous stent-assisted coiling using detachable coils and Onyx, which alleviated his symptoms. CLINICAL DISCUSSION A cavernous-carotid fistula following FESS is an exceedingly rare occurrence first reported by Karaman et al. in 2009. The incidence of internal carotid artery injury during FESS or endonasal endoscopic surgery (EES) is estimated to be between 0 and 0.1 %. Currently, there is no definitive explanation for the development of a carotid-cavernous fistula (CCF) post-FESS. Previous studies suggest that procedures like transsphenoidal surgery and EES can induce pseudoaneurysms in the internal carotid artery. If the cavernous pseudoaneurysm ruptures, it could lead to the formation of a CCF. CONCLUSION A direct cavernous-carotid fistula following functional endoscopic sinus surgery is a very rare. Consequently, when encountering patients with a carotid-cavernous fistula, relevant procedure history should be considered.
Collapse
Affiliation(s)
- Shu-Wei Chen
- Department of Surgery, Hualien Armed Forces General Hospital, Hualien, Taiwan, ROC; Department of Neurosurgery, Hualien Tzu-Chi Hospital, Hualien, Taiwan, ROC
| | - Chien-Hui Lee
- Department of Neurosurgery, Hualien Tzu-Chi Hospital, Hualien, Taiwan, ROC; Tzu-Chi University, Hualien, Taiwan, ROC.
| |
Collapse
|
32
|
Sun C, Wang J, Guo Q, Zhang Y. Red-eye symptoms caused by cavernous-sinus dural arteriovenous fistula: A rare case report. Asian J Surg 2024; 47:3550-3552. [PMID: 38724353 DOI: 10.1016/j.asjsur.2024.04.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/18/2024] [Indexed: 01/30/2025] Open
Affiliation(s)
- Chenglin Sun
- Department of Neurology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, Hubei, 441000, China
| | - Jiaqi Wang
- Department of Ophthalmology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, Hubei, 441000, China
| | - Qi Guo
- Department of Ophthalmology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, Hubei, 441000, China
| | - Yaqiong Zhang
- Department of Ophthalmology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, Hubei, 441000, China.
| |
Collapse
|
33
|
Su X, Ma Y, Song Z, Zhang P, Zhang H. Intracranial dural arteriovenous fistulas with pial arterial supply: A narrative review. Brain Circ 2024; 10:205-212. [PMID: 39526112 PMCID: PMC11542758 DOI: 10.4103/bc.bc_12_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 11/16/2024] Open
Abstract
Intracranial dural arteriovenous fistula (DAVF) is a relatively complex intracranial condition, and its clinical presentation and treatment strategies often vary significantly due to various factors. Although the cure rate of intracranial DAVF is currently high, there is still a lack of understanding of its etiology and pathogenesis. There is ongoing controversy regarding the treatment strategies for DAVF associated with the pial arteries, and there is a lack of understanding of its pathogenesis. The author conducted a brief literature review on DAVF with pial arterial supply and presented some treatment experiences from their own medical center. Large-scale retrospective cohort studies and prospective research in future are expected to address these issues.
Collapse
Affiliation(s)
- Xin Su
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zihao Song
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
34
|
Vranic JE, Regenhardt RW, Awad A, Doron O, Rabinov J. Endovascular and medical management strategies for carotid-cavernous fistulas: A safety and efficacy analysis. Interv Neuroradiol 2024:15910199241261761. [PMID: 38881351 PMCID: PMC11571441 DOI: 10.1177/15910199241261761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Carotid-cavernous fistulas (CCFs) are complex arteriovenous shunting lesions of the cavernous sinus with diverse clinical presentations. This study aimed to analyze clinical outcomes and differentiate patients treated with conservative observation versus those needing endovascular intervention. METHODS A retrospective analysis of 84 patients with angiographically confirmed CCF was conducted from 2000 to 2022. Endovascular treatment decisions were made at the discretion of neurointerventionalists. Clinical and angiographic data were collected, including Barrow CCF classification and treatment outcomes. RESULTS Patients managed conservatively (n = 17) had longer symptom duration (165 vs 42 days) and more indirect CCF (100% vs 68%) compared to those treated with endovascular embolization (n = 67). High-risk clinical symptoms, including proptosis, diplopia, decreased visual acuity, and chemosis, were more common in the embolization group. Cortical venous reflux and ophthalmic venous reflux were more prevalent in the embolization group (39% and 91%, respectively). Overall, 31% of embolized CCFs required retreatment, mainly Barrow type D lesions (65%). Transvenous coil embolization was the primary technique used (78%), followed by feeder artery embolization (16%), and internal carotid artery flow diversion (8%). CONCLUSION In selected CCF patients without high-risk symptoms or angiographic features, conservative observation is a safe and effective alternative to endovascular embolization. High-risk symptoms and angiographic features favor endovascular intervention. Complications were rare, and most were transient, emphasizing the safety of endovascular management. Longitudinal angiographic and ophthalmologic surveillance is essential for monitoring fistula persistence or recurrence.
Collapse
Affiliation(s)
- Justin E. Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W. Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amine Awad
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
35
|
Song Z, Ma Y, Su X, Fan Y, Zhang H, Ye M, Zhang P. Clinical features, treatment, and outcomes of cavernous sinus dural arteriovenous fistulas: a cohort study of 141 patients. Acta Neurol Belg 2024; 124:803-811. [PMID: 37924471 DOI: 10.1007/s13760-023-02405-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/09/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE The cavernous sinus (CS) region is a common region of dural arteriovenous fistula (DAVF). Over time, treatment strategies are gradually changing. In this study, we present our center's experience in managing CS-DAVF over the past 20 years. METHODS Medical records of patients diagnosed with CS-DAVF between 2002 and 2021 were collected for analysis. Patients meeting the predefined inclusion and exclusion criteria were included. This study summarized and analyzed their clinical characteristics, CS-DAVF angioarchitecture, treatment strategies, and outcomes. RESULTS A total of 141 patients (mean age 55 years, 46 males) were included in this study. Ocular/orbital symptoms were the most frequently reported initial symptoms, with 84 (59.6%) patients experiencing these symptoms first. Presentation with ocular/orbital symptoms as the first symptom was associated with thrombosis of the inferior petrosal sinus (p = 0.032). Presentation with headache/dizziness and tinnitus/intracranial murmur as the first symptom was associated with sphenoparietal sinus/superficial middle cerebral vein drainage (p = 0.011). Among the patients, 131 (92.9%) patients received endovascular treatment, with 114 (87.0%) undergoing transvenous embolization. Onyx (92.4%) and coil (74.8%) were the most used embolic materials. 17 (13.0%) of the patients who received endovascular treatment suffered intraoperative or postoperative complications, and 11 (64.7%) patients fully recovered within 6 months after discharge. CONCLUSION Ocular/orbital symptoms were the most common first symptom of CS-DAVF. The mode of venous drainage played a significant role in determining the first symptoms. Transvenous embolization using Onyx or a combination of Onyx and coils was the primary treatment modality.
Collapse
Affiliation(s)
- Zihao Song
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Xin Su
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Yuxiang Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
- China International Neuroscience Institute (China-INI), Beijing, China.
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
- China International Neuroscience Institute (China-INI), Beijing, China.
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
- China International Neuroscience Institute (China-INI), Beijing, China.
| |
Collapse
|
36
|
Mori T, Fujita A, Iwahashi H, Ikeda M, Morikawa M. Direct carotid-cavernous fistula presenting with intracranial hemorrhage without ocular symptoms. Radiol Case Rep 2024; 19:2418-2421. [PMID: 38585394 PMCID: PMC10997862 DOI: 10.1016/j.radcr.2024.02.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 04/09/2024] Open
Abstract
Herein, we report a unique case of nontraumatic direct carotid-cavernous fistula presenting with intracerebral hemorrhage without any ocular symptoms. A 90-year-old woman was found unconscious and vomiting due to a subcortical hemorrhage in the temporal lobe. Magnetic resonance angiography revealed a direct carotid-cavernous fistula of Barrow type A. Extensive cortical venous reflux from the superficial middle cerebral vein was observed and identified as a probable contributor to the cerebral hemorrhage. We performed successful embolization using combined transarterial and transvenous approaches. We first occluded the dangerous venous drainage via the transvenous approach, followed by selective occlusion of the direct carotid-cavernous fistula via the transarterial approach. This strategy provided that the dangerous venous drainage was completely occluded first in case complete obliteration could not be achieved with the transarterial approach.
Collapse
Affiliation(s)
- Tatsuya Mori
- Department of Neurosurgery, Yodogawa Christian Hospital, Osaka, Japan, Osaka, 533-0024, Japan
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirofumi Iwahashi
- Department of Neurosurgery, Yodogawa Christian Hospital, Osaka, Japan, Osaka, 533-0024, Japan
| | - Mitsuru Ikeda
- Department of Neurosurgery, Yodogawa Christian Hospital, Osaka, Japan, Osaka, 533-0024, Japan
| | - Masashi Morikawa
- Department of Neurosurgery, Yodogawa Christian Hospital, Osaka, Japan, Osaka, 533-0024, Japan
| |
Collapse
|
37
|
Cohen DA, Sanchez Moreno FR, Bhatti MT, Lanzino G, Chen JJ. Evaluating the Incidence and Neuro-Ophthalmic Manifestations of Carotid-Cavernous Fistulas. J Neuroophthalmol 2024; 44:232-235. [PMID: 37581565 PMCID: PMC10864674 DOI: 10.1097/wno.0000000000001973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
BACKGROUND To determine the incidence of carotid-cavernous fistula (CCF) and describe the neuro-ophthalmic manifestations and eventual clinical outcomes. METHODS This was a population-based, retrospective cohort study using the Rochester Epidemiology Project to identify patients aged 18 years or older residing in Olmsted County, MN, diagnosed with CCF from 1997 to 2019. The medical records were reviewed for ophthalmic signs and symptoms, including conjunctival chemosis, proptosis, orbital bruit, diplopia, ophthalmoplegia, orbital pain, ocular hypertension, and blurred vision. Also determined was the number of patients with CCF found incidentally on neuroimaging, without clinical manifestations. RESULTS Ten patients were diagnosed with a CCF between 1997 and 2019 with an overall incidence rate of 0.37 per 100,000 per year (95% CI 0.20-0.68). The median age was 50.5 years (range 23-74 years), 6 (60%) were female, and 9 were White and 1 patient was Korean. Three patients (30%) were asymptomatic and found incidentally on imaging that was obtained for unrelated reasons, and one patient's ocular details were unavailable because she passed away from severe head trauma. The following neuro-ophthalmologic or ocular manifestations were identified in the remaining 6 patients: chemosis/conjunctival injection (n = 6), cranial nerve (CN) VI palsy (n = 6), CN III palsy (n = 2), proptosis (n = 4), ocular/orbital pain (n = 3), audible orbital bruit (n = 2), ocular hypertension (n = 1), and blurred vision (n = 1). Of those patients with symptomatic CCFs, all underwent treatment except for one that spontaneously resolved. None of the patients suffered a stroke or cerebral hemorrhage. The 3 patients with incidentally discovered CCFs were asymptomatic and did not require treatment. CONCLUSIONS This is the first population-based study to show a low incidence rate of CCFs, supporting the notion that it is an uncommon condition. Neuro-ophthalmic manifestations are common, especially chemosis/conjunctival injection and CN VI palsy. Up to a third of patients with CCF can be asymptomatic and may be found incidentally on neuroimaging during the evaluation for unrelated symptoms.
Collapse
Affiliation(s)
- Devon A. Cohen
- Department of Ophthalmology, Cleveland Clinic Foundation, Cleveland, OH
| | | | - M. Tariq Bhatti
- Department of Ophthalmology, The Permanente Medical Group, Roseville, CA
| | | | - John J. Chen
- Department of Neurology, Mayo Clinic, Rochester, MN
- Department of Ophthalmology, Mayo Clinic, Rochester, MN
| |
Collapse
|
38
|
Phuyal S, Thapa Chhetri S, Phuyal P, Khanal D, Paudel S. Direct carotid cavernous fistula treated with transvenous approach: a case report. Ann Med Surg (Lond) 2024; 86:3796-3799. [PMID: 38846860 PMCID: PMC11152878 DOI: 10.1097/ms9.0000000000002151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/30/2024] [Indexed: 06/09/2024] Open
Abstract
Introduction Carotid cavernous fistulas are uncommon vascular abnormalities marked by anomalous connections between the carotid artery and the cavernous sinus. The authors present a case of a direct carotid cavernous fistula and its successful treatment in a 42-year-old female. Case presentation A 42-year-old female presented with right eye painful swelling and visual disturbance. She had no known comorbidities or history of injury. Examination showed proptosis, chemosis, and orbital bruit. Carotid angiography confirmed a carotid cavernous fistula, which was managed endovascularly. The patient fully recovered after treatment. Discussion Carotid cavernous fistula occurs spontaneously or as a result of trauma or other vascular abnormalities. Common clinical manifestations include proptosis, chemosis, and orbital bruit, with vision loss being a feared complication. Diagnosis is typically confirmed through angiography, with digital subtraction angiography being the gold standard. Endovascular treatment is usually effective, although surgical management may be necessary in certain cases. Conclusion Carotid cavernous fistula is a rare but potentially sight-threatening neurological condition. Treatment with a transvenous approach is effective for the management of direct carotid cavernous fistula.
Collapse
Affiliation(s)
- Subash Phuyal
- Department of Neuroradiology, Upendra Devkota Memorial National Institute of Neurology and Allied Sciences
| | | | - Prakash Phuyal
- Department of Neuroradiology, Upendra Devkota Memorial National Institute of Neurology and Allied Sciences
| | - Deepa Khanal
- Manipal College of Medical Sciences Pokhara, Pokhara, Nepal
| | | |
Collapse
|
39
|
Wu YM, Lin CM, Giri S, Chen YL, Chang CH, Wong HF. Comparing transvenous coiling and transarterial embolization with Onyx/NBCA for cavernous sinus dural arteriovenous fistulas: A retrospective study in a single center. Biomed J 2024; 47:100657. [PMID: 37660902 PMCID: PMC11220534 DOI: 10.1016/j.bj.2023.100657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 08/08/2023] [Accepted: 08/30/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND Endovascular management is the gold standard for cavernous sinus dural arteriovenous fistulas (CS-dAVFs) in patients with signs of ophthalmoplegia, visual defects, or intolerable clinical symptoms. Although the efficacy of embolization has been confirmed, complications during post-endovascular management have not been compared in a more extensive CS-dAVFs case series. Therefore, we compared the effectiveness and peri-procedural complications of transvenous coiling with those of transarterial embolization (TAE) using liquid embolic agents. METHODS We reviewed 71 patients with CS-dAVFs in one medical center from 2005/7 to 2016/7. We performed seventy-seven procedures on 71 patients, including six recurrent cases. We compared the efficacy and peri-procedural complications of transvenous coiling and TAE. RESULTS The complete occlusion rate for transvenous coiling was 79.2%, and that for TAE was 75.0%. Findings revealed (1) similar ophthalmoplegia complication rates (p = 0.744); (2) more frequent and permanent CN5 or CN7 neuropathy with liquid embolic agent use (p = 0.031 and 0.028, respectively); and (3) a higher risk of infarction or ICH (p = 0.002 and 0.028, respectively) in response to aggressive TAE. CONCLUSION Transvenous cavernous sinus coiling resulted in a similar occlusion rate and lower complication risk than transarterial Onyx/n-butyl cyanoacrylate (NBCA). We can access via an occluded inferior petrosal sinus (even contralateral), and direct transorbital puncture was a safe alternative. TAE with Onyx/NBCA was helpful in cases of oligo-feeders, but multidisciplinary treatment and multi-session TAE were usually needed for patients with multiple feeders and complex fistulas.
Collapse
Affiliation(s)
- Yi-Ming Wu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chuan-Min Lin
- Department of Neurology, New Taipei Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei, Taiwan
| | - Sachin Giri
- Fellowship in Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; Dr L.H. Hiranandani Hospital, Powai, Mumbai, India
| | - Yao-Liang Chen
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chang
- Department of Neurology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ho-Fai Wong
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
40
|
Kosarchuk J, Patel S, Dent W, Hedges T, Malek A, Heilman C. Open Surgical Obliteration of Three Indirect Carotid-Cavernous Fistulas. Oper Neurosurg (Hagerstown) 2024; 26:743-748. [PMID: 38189489 DOI: 10.1227/ons.0000000000001038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/08/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND AND IMPORTANCE Carotid-cavernous fistulas (CCFs) are abnormal connections between the carotid artery and the cavernous sinus (CS). CCFs are primarily treated by an endovascular route, but there are situations in which a lesion is not amenable to endovascular or transorbital treatment, necessitating a transcranial approach. In this select group of patients, the use of crushed temporalis muscle to pack the CS fistula site was found to be an effective method for treatment of CCFs. CLINICAL PRESENTATION In this case series, we present 3 patients with CCFs in which endovascular treatment was not possible because of occlusion of the petrosal sinuses or stenosis of the superior ophthalmic vein at the superior orbital fissure, rendering the lesion inaccessible by a transvenous or transorbital route. Each patient was treated with a variation of temporalis muscle packing through a skull base triangle; one was treated through the anteromedial triangle, one through the supratrochlear triangle, and the third through the Parkinson triangle. The fistulas were cured in each case. CONCLUSION Cavernous-carotid fistulas that are not amenable to endovascular or transorbital treatment can be successfully treated by packing the CS fistula site with crushed temporalis muscle. To cure these patients' symptoms and enhance their quality of life, it is crucial to weigh the advantages and disadvantages of each therapy option.
Collapse
Affiliation(s)
- Jacob Kosarchuk
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston , Massachusetts , USA
| | - Shrey Patel
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston , Massachusetts , USA
| | - Walter Dent
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston , Massachusetts , USA
| | - Thomas Hedges
- Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston , Massachusetts , USA
| | - Adel Malek
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston , Massachusetts , USA
| | - Carl Heilman
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston , Massachusetts , USA
| |
Collapse
|
41
|
Shrestha P, Shrestha A, Shrestha T, Shrestha RM, Kesari R, Shrestha N, Gupta R. Indirect Carotid Cavernous Fistula with Ocular Manifestations: A Case Report. JNMA J Nepal Med Assoc 2024; 62:407-410. [PMID: 39356861 PMCID: PMC11185313 DOI: 10.31729/jnma.8615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Indexed: 10/04/2024] Open
Abstract
ABSTRACT Carotid-cavernous fistulas are rare entity with incidence of less than 1%, refers to abnormal connections between the carotid artery and cavernous sinus. Indirect types usually occur in elderly female patients and can resolve spontaneously with conservative management like external manual compression of the carotid artery. We report a case of 65-year-old female who presented with complaints of redness, proptosis, chemosis, headache and ophthalmoplegia in her right eye. Digital subtraction angiography revealed Barrow type B indirect carotid-cavernous fistulas. External manual carotid compression was done after which her symptoms improved significantly. Thus, indirect type carotid-cavernous fistulas can occur spontaneously and could be a sight threatening condition especially in elderly females but can resolve with conservative management.
Collapse
Affiliation(s)
- Pooja Shrestha
- Department of Ophthalmology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Angira Shrestha
- Department of Ophthalmology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Tina Shrestha
- Department of Ophthalmology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Richa Makaju Shrestha
- Department of Ophthalmology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Rajani Kesari
- Department of Ophthalmology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Nigi Shrestha
- Department of Ophthalmology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Rahul Gupta
- Department of Ophthalmology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| |
Collapse
|
42
|
Uzundede T, Kırmacı Kabakcı A, Yıldız Ö, Taşkıran Çömez A. A Troublesome Case of Indirect Carotid-Cavernous Fistula Presenting with Proptosis without Pulsation. Klin Monbl Augenheilkd 2024; 241:661-665. [PMID: 36414022 DOI: 10.1055/a-1984-1031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Tahsin Uzundede
- Ophthalmology, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | | | - Ömer Yıldız
- Radiology, Istanbul Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | | |
Collapse
|
43
|
Melanis K, Magoufis G, Spiliopoulos S, Lachanis S, Alonistiotis D, Papagiannopoulou G, Chondrogianni M, Bakola E, Tsivgoulis G. Carotid-cavernous fistula: A potential treatable cause of bilateral abducens palsy and conjunctival hyperemia. J Stroke Cerebrovasc Dis 2024; 33:107623. [PMID: 38311093 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 02/06/2024] Open
Abstract
OBJECTIVE Carotid cavernous fistulas (CCFs) represent uncommon and anomalous communications between the carotid artery and the cavernous sinus. MATERIALS AND METHODS Case report RESULTS: We present the clinical details and successful management of a previously healthy 44-year-old patient who presented with one-month worsening headache, bilateral abducens palsy and conjunctival injection. Imaging modalities including magnetic resonance imaging (MRI) with contrast and digital subtraction angiography (DSA) facilitated the diagnosis of CCF. The patient underwent endovascular coiling of the CCF, leading to neurological recovery and symptom remission. CONCLUSION This case highlights the importance of promptly CCF diagnosis in patients with multiple cranial nerve palsies and conjunctival hyperemia. Moreover, it emphasizes the efficacy of endovascular coiling in achieving symptom remission.
Collapse
Affiliation(s)
- Konstantinos Melanis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | | | - Stavros Spiliopoulos
- Interventional Radiology Department, "Attikon" University Hospital, Athens, Greece
| | | | - Dimitrios Alonistiotis
- Second Department of Ophthalmology, University of Athens Medical School, "Attikon" University General Hospital, Athens, Greece
| | - Georgia Papagiannopoulou
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | - Maria Chondrogianni
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece.
| |
Collapse
|
44
|
Voldřich R, Grygar J, Charvát F, Netuka D. Natural course of partially embolized carotid-cavernous fistulas. J Neuroimaging 2024; 34:376-385. [PMID: 38343141 DOI: 10.1111/jon.13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND AND PURPOSE To present the first study analyzing the clinical and radiological course of carotid-cavernous fistulas (CCFs) following incomplete embolization. The study compares magnetic resonance angiography (MRA) to plain angiography (digital subtraction angiography [DSA]) and investigates the long-term ophthalmological impact of residual fistula. METHODS Fistulas classified as partially embolized after the last endovascular treatment were prospectively followed with DSA, MRA, and ophthalmological examination. Both direct and indirect CCFs were included. RESULTS Twenty-one CCFs were included in the study. Nine (43%) fistulas were direct and 12 (57%) were indirect. A favorable clinical outcome of modified Rankin scale ≤2 was recorded in 19 (90%) patients at the last follow-up. Postinterventional ophthalmologic examinations in 16 patients revealed no negative effects of residual fistulas; five remaining patients refused to undergo further examination. Spontaneous thrombosis and complete occlusion of the CCF were demonstrated in 90% of patients, with a mean time to occlusion of 5.7 ± 4.7 months. Fourteen (66%) patients completed the full imaging follow-up (MRA and DSA). In 21% of these cases, discrepancy between the two imaging modalities was observed-MRA failed to detect persistent fistulas identified by DSA. CONCLUSIONS The goal of CCF treatment is safe and complete embolization. However, if adequate flow reduction is achieved, both direct and indirect CCFs tend to spontaneously thrombose. Residual flow does not result in ophthalmological deterioration until the fistula is completely closed. MRA may not be sufficiently sensitive to detect residues of fistulas including cortical venous drainage. Therefore, complete CCF closure should be confirmed through DSA.
Collapse
Affiliation(s)
- Richard Voldřich
- Department of Neurosurgery and Neurooncology, Charles University, First Faculty of Medicine, Military University Hospital, Prague, Czech Republic
| | - Jan Grygar
- Department of Ophthalmology, Charles University, First Faculty of Medicine, Military University Hospital, Prague, Czech Republic
| | - František Charvát
- Department of Radiology, Military University Hospital, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, Charles University, First Faculty of Medicine, Military University Hospital, Prague, Czech Republic
| |
Collapse
|
45
|
Iampreechakul P, Wangtanaphat K, Chuntaroj S, Wattanasen Y, Hangsapruek S, Lertbutsayanukul P, Puthkhao P, Siriwimonmas S. Pseudoaneurysm formation following transarterial embolization of traumatic carotid-cavernous fistula with detachable balloon: An institutional cohort long-term study. World J Radiol 2024; 16:94-108. [PMID: 38690547 PMCID: PMC11056853 DOI: 10.4329/wjr.v16.i4.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/04/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND The goal of therapy for traumatic carotid-cavernous fistula (TCCF) is the elimination of fistula while maintaining patency of the parent artery. The treatment for TCCF has evolved from surgery to endovascular management using detachable balloons, coils, liquid embolic agents, covered stents, or flow-diverter stent through arterial or venous approaches. Despite the withdrawal of detachable balloons from the market in the United States since 2004, transarterial embolization with detachable balloons has currently remained the best initial treatment for TCCF in several countries. However, the pseudoaneurysm formation following transarterial detachable balloon embolization has rarely been observed in long-term follow-up. AIM To determine the occurrence and long-term follow-up of pseudoaneurysm after transarterial detachable balloon for TCCF. METHODS Between January 2009 and December 2019, 79 patients diagnosed with TCCF were treated using detachable latex balloons (GOLDBAL) of four sizes. Pseudoaneurysm sizes were stratified into five grades for analysis. Initial and follow-up assessments involved computed tomography angiography at 1 month, 6 month, 1 year, and longer intervals for significant cases. Clinical follow-ups occurred semi-annually for 2 years, then annually. Factors analyzed included sex, age, fistula size and location, and balloon size. RESULTS In our cohort of 79 patients treated for TCCF, pseudoaneurysms formed in 67.1%, with classifications ranging from grade 0 to grade 3; no grade 4 or giant pseudoaneurysms were observed. The majority of pseudoaneurysms did not progress in size, and some regressed spontaneously. Calcifications developed in most large pseudoaneurysms over 5-10 years. Parent artery occlusion occurred in 7.6% and recurrent fistulas in 16.5%. The primary risk factors for pseudoaneurysm formation were identified as the use of specific balloon sizes, with balloon SP and No. 6 significantly associated with its occurrence (P = 0.005 and P = 0.002, respectively), whereas sex, age, fistula size, location, and the number of balloons used were not significant predictors. CONCLUSION Pseudoaneurysm formation following detachable balloon embolization for TCCF is common, primarily influenced by the size of the balloon used. Despite this, all patients with pseudoaneurysms remained asymptomatic during long-term follow-up.
Collapse
Affiliation(s)
- Prasert Iampreechakul
- Department of Neurosurgery, Neurological Institute of Thailand, Bangkok 10400, Thailand
| | | | - Songpol Chuntaroj
- Department of Neuroradiology, Neurological Institute of Thailand, Bangkok 10400, Thailand
| | - Yodkhwan Wattanasen
- Department of Neuroradiology, Neurological Institute of Thailand, Bangkok 10400, Thailand
| | - Sunisa Hangsapruek
- Department of Neuroradiology, Neurological Institute of Thailand, Bangkok 10400, Thailand
| | | | - Pimchanok Puthkhao
- Department of Medical Services, Neurological Institute of Thailand, Bangkok 10400, Thailand
| | - Somkiet Siriwimonmas
- Department of Radiology, Bumrungrad International Hospital, Bangkok 10110, Thailand
| |
Collapse
|
46
|
Pensak ML. The cavernous sinus: An anatomic study with clinical implication. Laryngoscope Investig Otolaryngol 2024; 9:e1226. [PMID: 38525119 PMCID: PMC10960246 DOI: 10.1002/lio2.1226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/21/2024] [Indexed: 03/26/2024] Open
Abstract
Objective The management of lesions involving the cavernous sinus remains a formidable challenge. To optimize care for patients with tumors extending into this skull base region a detailed understanding of the surrounding osteology as well as neural and vascular relationships is requisite. This thesis examines the gross anatomy of the region and highlights important surgical implications drawn from these as well as previously published studies. Methods A review of the historical scientific, anatomic, clinical, and surgical literature extending to the present (1992) relating to the cavernous sinus has been performed and discussed. Additionally, the author has performed and described cadaveric dissections revealing novel details about the macroscopic (dural and neurovascular anatomic relationships) and microscopic structure of the cavernous sinus. A series of cases of cavernous sinus pathologies that were addressed in an interdisciplinary surgical approach at the author's institution is also reported. Results Included in this report is a comprehensive review of the embryology of the cavernous sinus and its associated neurovascular structures. Cadaveric dissections have also revealed novel details about dural/meningeal compartments of the cavernous sinus as well as well as associated arterial, venous, and neural relationships. Microscopic observations also reveal novel fundamental insights into the components and structure of the cavernous sinus. Clinical examples from 20 patients illustrate the critical importance for clinical application of cavernous sinus anatomic knowledge to the surgical treatment of pathologies in this region. Conclusion The cavernous sinus is a tripartite venous osteomeningeal compartment intimately neighboring vital structures including the optic tracts, pituitary gland, cranial nerves III, IV, V, V, VI, and the internal carotid artery. Surgical management of cavernous sinus lesions has and continues to evolve with increasing anatomic and clinical study as well as advancements in diagnostic and surgical methodologies. Level of Evidence NA.
Collapse
Affiliation(s)
- Myles L. Pensak
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| |
Collapse
|
47
|
Voura EB, Stulb JR, Eller JL, Padalino DJ, Ramaswamy R. Delayed Iatrogenic Direct Carotid Cavernous Fistula Following Flow Diversion for Aneurysm With Spontaneous Healing: A Case Report. Cureus 2024; 16:e58944. [PMID: 38800138 PMCID: PMC11126303 DOI: 10.7759/cureus.58944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
An abnormal connection between the carotid artery and cavernous sinus is referred to as a carotid cavernous fistula (CCF). A direct CCF results when the connection occurs between the intracranial internal carotid artery (ICA) and the cavernous sinus. These events are typically the result of a head injury, but can also be iatrogenic, resulting from various intracranial procedures. Direct CCF occurrences rarely heal spontaneously due to the high flow rate across the fistula. In this report, we present an uncommon case involving a delayed iatrogenic direct CCF, which developed following the placement of a pipeline flow-diverting stent that was used to treat a cerebral aneurysm. Interestingly, this unusual iatrogenic direct CCF subsequently spontaneously resolved within a few months. To our knowledge, this is the only case of a delayed CCF occurring with the use of a flow-diverting sent, which then resolved on its own. This report recounts our experience with the case.
Collapse
Affiliation(s)
- Evelyn B Voura
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
- Department of Neuroscience and Physiology, State University of New York Upstate Medical University, Syracuse, USA
| | - John R Stulb
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
| | - Jorge L Eller
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
| | - David J Padalino
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
| | - Raghu Ramaswamy
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
| |
Collapse
|
48
|
Yilmaz U. [Carotid-cavernous fistulas]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:182-188. [PMID: 38351202 DOI: 10.1007/s00117-024-01269-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Carotid cavernous fistulas (CCFs) are rare but clinically significant vascular anomalies characterized by abnormal connections between the cavernous sinus and arteries. This overview presents a comprehensive analysis of anatomy, classification, clinical presentation, diagnosis, imaging, and therapy of CCFs. The cavernous sinus, a central venous structure in the brain, is of critical importance for understanding CCFs due to its proximity to key structures such as the internal carotid artery and cranial nerves. CLASSIFICATION CCFs are classified into direct and dural types, with direct fistulas typically being high-flow and dural fistulas being low-flow. The symptomatology varies greatly and can range from noises in the head, diplopia, red eye, tearing, to blurred vision and headaches. The diagnostic assessment requires a combination of detailed medical history, neurological and ophthalmological examination, and the use of imaging techniques. METHODS In imaging, computed tomography (CT) and magnetic resonance imaging (MRI) are crucial for depicting the anatomical structures and blood vessels, while digital subtraction angiography (DSA) is considered the gold standard for accurate representation of the fistula. The treatment of CCFs is complex and depends on the type of fistula, location, and clinical condition of the patient. CONCLUSION This overview emphasizes the importance of precise diagnosis and individualized therapy to achieve optimal results and avoid complications. Ongoing developments in medical imaging and treatment techniques will continuously improve the treatment outcomes of patients with CCFs.
Collapse
Affiliation(s)
- Umut Yilmaz
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Kirrberger Str., Gebäude 90.4, 66421, Homburg, Deutschland.
| |
Collapse
|
49
|
Lopes EMP, Ludovico IC, Mota CDMG, Xavier ACM, Duarte AF, Cardigos JSD. Surgical management of glaucoma secondary to indirect carotid-cavernous fistula: A case report. Int J Surg Case Rep 2024; 116:109317. [PMID: 38354573 PMCID: PMC10943638 DOI: 10.1016/j.ijscr.2024.109317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Indirect carotid-cavernous fistula (CCF) can lead to secondary glaucoma, posing significant treatment challenges. This paper discusses a case where standard embolization failed, and an Ahmed FP7 valved glaucoma tube shunt was crucial for managing the increased intraocular pressure (IOP), highlighting the necessity for individualized surgical approaches. CASE PRESENTATION A 48-year-old female presented in the emergency department with conjunctival hyperemia, proptosis and elevated IOP; initial imaging findings were indicative of orbital inflammatory disease. Further evaluation with cerebral CT angiography revealed a possible CCF. Subsequent angiography confirmed an indirect CCF type D, leading to the patient undergoing endovascular embolization. Final monitoring revealed a subtotal occlusion of the fistula. Although there was some improvement post-procedure, IOP remained elevated despite medication, and subsequent attempts of embolization were unsuccessful. Surgical intervention with a tube shunt was performed, allowing IOP to decreased to a normal range. Optic nerve head optical coherence tomography, standard automated perimetry, and best-corrected visual acuity remained stable during the 33-month follow-up. DISCUSSION In managing glaucoma linked to CCF, a multidisciplinary approach is critical. Conservative methods are often adequate, with spontaneous CCF closure observed in a significant percentage. Endovascular embolization is reserved for refractory cases, with embolization showing a higher rate of IOP normalization compared to medication alone. Yet, when fistula closure is challenging or contraindicated, individualized management strategies like glaucoma surgery may be employed. CONCLUSIONS When fistula closure is not achievable, the Ahmed FP7 valved tube shunt can successfully regulate IOP with minimal complications, providing an effective alternative for refractory cases.
Collapse
Affiliation(s)
| | - Inês Cerqueira Ludovico
- Ophthalmology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | | | | | - Ana Filipa Duarte
- Ophthalmology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | | |
Collapse
|
50
|
Yadav R, Hosur B, Rangan NM, Roy ID, Tomar K, Desai AP, Manimaran R, Krishnan M. Carotid Cavernous Fistula as a Rare and Late Complication of Maxillofacial Injury: A Brief Clinical Study. J Craniofac Surg 2024:00001665-990000000-01322. [PMID: 38315755 DOI: 10.1097/scs.0000000000009990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/16/2023] [Indexed: 02/07/2024] Open
Abstract
Carotid- Cavernous Fistula (CCF) represents an aberrant vascular communication at the skull base between the high-flow carotid arterial system and the low-flow venous channels within the cavernous sinuses of the sphenoid bone. Benjamin Travers, in the year 1809, described this condition as "pulsating exophthalmos". This case is a presentation of a carotid cavernous fistula in an operated case of maxillofacial injury as a late complication. The individual presented with a nonresolving proptosis and chemosis for the past 9 weeks. This presentation enumerates how the diagnosis was made, though being a rare complication and how it was promptly managed that resulted in a remarkable resolution of signs and symptoms.
Collapse
Affiliation(s)
- Rekha Yadav
- Department of Dental Surgery and Oral Health Sciences
| | - Bharat Hosur
- Department of Radiodiagnosis, Armed Forces Medical College, Pune, India
| | | | | | - Kapil Tomar
- Department of Dental Surgery and Oral Health Sciences
| | - Ajay P Desai
- Department of Dental Surgery and Oral Health Sciences
| | | | | |
Collapse
|