Treatment of carotid cavernous fistulas

Carotid Cavernous Fistula

Carotid cavernous fistulae (CCFs) are arteriovenous shunts involving the cavernous sinus. CCFs are defined as direct or indirect. Direct CCFs are treated by deconstructive or reconstructive techniques depending on whether the affected internal carotid artery is required to perfuse the ipsilateral cerebral hemisphere, as determined by a balloon test occlusion. Indirect CCFs, or dural fistulae of the cavernous sinus wall, are most often treated with transvenous embolization. Stereotactic radiosurgery is reserved for cases of indirect CCFs that are not completely obliterated by embolization. Overall, cure rates are high with relatively low complication rates.

Endovascular treatment of direct carotid cavernous fistula resulting from rupture of intracavernous carotid aneurysm: A case report

BACKGROUND

Direct carotid cavernous fistulas (CCFs) are typically the result of a severe traumatic brain injury. High-flow arteriovenous shunts secondary to rupture of an intracavernous aneurysm, resulting in direct CCFs, are rare. The use of a pipeline embolization device in conjunction with coils and Onyx glue for treatment of direct high-flow CCF resulting from ruptured cavernous carotid artery aneurysm in a clinical setting is not well documented.

CASE SUMMARY

A 58-year-old woman presented to our department with symptoms of blepharoptosis and intracranial bruits for 1 wk. During physical examination, there was right eye exophthalmos and ocular motor palsy. The rest of the neurological examination was clear. Notably, the patient had no history of head injury. The patient was treated with a pipeline embolization device in the ipsilateral internal carotid artery across the fistula. Coils and Onyx were placed through the femoral venous route, followed by placement of the pipeline embolization device with assistance from a balloon-coiling technique. No intraoperative or perioperative complications occurred. Preoperative symptoms of bulbar hyperemia and bruits subsided immediately after the operation.

CONCLUSION

Pipeline embolization device in conjunction with coiling and Onyx may be a safe and effective approach for direct CCFs.

Intermittent Manual Carotid Compression as a Treatment Option for Indirect Low Flow Carotid Cavernous Fistula

PURPOSE

To evaluate the efficacy of intermittent manual carotid compression (IMCC) in the management of low-flow carotid cavernous fistulae (CCF).

MATERIALS AND METHODS

Patients diagnosed with low-flow CCF and treated with IMCC over a period of 13 years were retrospectively analyzed. Data analyzed included demographic details, clinical features, type of CCF, and response to therapy. Outcomes were categorized as complete cure, partial cure, and no cure or worsening. Patients with complete and partial cure were grouped as good outcome whereas those with no cure or worsening as poor outcome.

RESULTS

A total of 44 patients were advised IMCC for low-flow CCF, of whom five were lost to follow-up. Results of the remaining 39 patients were analyzed, of whom 21 (53.8%) were males. The mean age at presentation was 54.38 ± 14.54 years. The median duration between the onset of symptoms and presentation was 5.0 ± 4.10 months. The common presenting features were episcleral congestion and proptosis (89.7%), extraocular motility restriction (66.7%), and diplopia (48.7%). Most common CCF type was type D (34, 87.2%). All patients were advised to undergo IMCC. Good outcome was seen in 35 patients (89.7%, 95% CI: 80.2% to 99.2%), whereas poor outcome was seen in four (10.3%) patients. The mean duration of follow-up was 15.91 ± 21.87 months.

CONCLUSION

The present study found a good outcome with IMCC in 89.7% cases of indirect low-flow CCF with no major complications. It should be considered the management of choice in patients who are systemically unfit or cannot afford endovascular embolization.

Comparing transvenous coiling and transarterial embolization with Onyx/NBCA for cavernous sinus dural arteriovenous fistulas: a retrospective study in a single center

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.

MATERIAL AND 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.

Endovascular Intervention for a Carotid-Cavernous Fistula: A Case Report

A carotid-cavernous fistula is a rare vascular anomaly involving abnormal communication between the carotid artery and the cavernous sinus. This condition leads to the shunting of arterial blood directly into the venous system, causing diverse clinical manifestations. The classification includes direct and indirect fistulas, with endovascular techniques emerging as a preferred treatment option. In this report, we present the case of a 58-year-old male who presented with progressive right-sided proptosis, headache, and visual disturbances. He exhibited right abducens nerve palsy, reduced visual acuity, and a dilated superior ophthalmic vein on imaging. A multidisciplinary team confirmed the diagnosis of a carotid-cavernous fistula and chose to pursue endovascular embolization. Catheter angiography revealed the fistula and balloon-assisted occlusion restored normal arterial flow. The patient's symptoms improved, and follow-up showed complete resolution of proptosis and enhanced visual acuity. Successful endovascular embolization underscores the significance of a multidisciplinary approach and showcases the positive outcomes achievable when diverse specialties converge for patient well-being.

[Endovascular Treatment for Head and Neck Trauma]

Trauma to the head and neck region can have serious consequences for vital organs such as the brain, and injuries to blood vessels can cause permanent neurological damage or even death. Thus, prompt treatment of head and neck vessels is crucial. Although the level of evidence is moderate, an increasing amount of research indicates that endovascular treatments can be a viable alternative to traditional surgery or medical management. Embolization or reconstructive endovascular procedures can significantly improve patient outcomes. This article provides an overview of various endovascular options available for specific clinical scenarios, along with examples of cases in which they were employed.

Venous Pathologies and Interventions of the Head

Intracranial venous pathologies are a historically underrecognized group of disorders that can have a devastating impact on patients. Despite advancements in peripheral venous disorders and arterial neurointerventions, intracranial venous pathologies have received comparatively little attention. Understanding the anatomy, physiology, clinical relevance, and treatment options of intracranial venous pathologies is fundamental to evolving therapies and research priorities. This article provides an overview of major intracranial venous pathologies, the respective pathophysiologies, and treatment options.

High index of suspicion: diagnosing a carotid-cavernous fistula

A woman in her 70s presented with acute bilateral retro-orbital headache, diplopia, chemosis and eye swelling. Ophthalmology and neurology were consulted after detailed physical examination and diagnostic workup including laboratory analysis, imaging and lumbar puncture. The patient was diagnosed with non-specific orbital inflammation and was started on methylprednisolone and dorzolamide-timolol for intraocular hypertension. The patient's condition improved slightly, but a week later, she developed subconjunctival haemorrhage in the right eye, which prompted investigation for a low-flow carotid-cavernous fistula. Digital subtraction angiography showed bilateral indirect carotid-cavernous fistula (Barrow type D). The patient underwent bilateral carotid-cavernous fistula embolisation. Her swelling improved considerably on day 1 after the procedure and her diplopia improved over the following weeks.

Neuroendovascular Procedures in Patients with Ehlers-Danlos Type IV: Multicenter Case Series and Systematic Review

BACKGROUND

Ehlers-Danlos type IV or vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited disorder characterized by profound vascular fragility resulting from defective production of type III procollagen. Cerebrovascular diseases including spontaneous dissections, cerebral aneurysms, and cavernous carotid fistulae are common. Endovascular therapies in this patient population are known to be higher risk, although many studies (before 2000) involved older techniques and equipment. The purpose of this study is to investigate the safety and efficacy of modern neuroendovascular techniques in the treatment of cerebrovascular diseases in patients with vEDS.

METHODS

We combined a multi-institutional retrospective case series at 3 quaternary-care centers with a systematic literature review of individual case reports and case series spanning 2000-2021 to evaluate the safety and efficacy of neuroendovascular procedure in patients with vEDS with cerebrovascular diseases.

RESULTS

Fifty-nine patients who underwent 66 neuroendovascular procedures were evaluated. Most of the patients had direct cavernous carotid fistulas (DCCF). Neuroendovascular procedures had a 94% success rate, with a complication rate of 30% and a mortality of 7.5%.

CONCLUSIONS

Neuroendovascular procedures can be performed with a high rate of success in the treatment of cerebrovascular diseases in patients with vEDS, although special care is required because complication rates and mortality are high. Access site and procedure-related vascular injuries remain a significant hurdle in treating vEDS with cerebrovascular diseases, even with modern techniques.

Direct and Dural Carotid Cavernous Sinus Fistulas: Comparison of Clinical Characteristics

Purpose

To compare the clinical characteristics of patients with direct and dural carotid cavernous sinus fistulas (CCFs).

Methods

The medical records of 60 patients diagnosed with CCFs were retrospectively reviewed. The collected data included demographic characteristics, clinical findings, and ocular manifestation. The clinical characteristics of the direct and the dural CCFs were compared on head-to-head basis. Logistic regression analysis was used to demonstrate the direction and magnitude of the difference and reported as odds ratio with its 95% confidence interval.

Results

There were 28 patients (46.67%) with direct CCFs, and 32 patients (53.33%) with dural CCFs. Patients with direct CCF were mostly male (p=0.023), younger age (p<0.001), had history of trauma (p<0.001), and more visual impairment at presentation (p=0.025), when compared to those with dural CCFs. In addition, patients with direct CCF had significantly more chemosis (p=0.005), proptosis (p=0.042), bruit (p<0.001) and dilated retinal vessels (p=0.008) than those with dural CCF. Thirty patients (50%) had increased intraocular pressure (IOP). Mean IOP of the affected eyes was significantly higher than the unaffected eyes (p<0.0001). In patients with normal IOP, mean IOP of the affected eyes was also higher than the unaffected eyes (p=0.0027).

Conclusion

Patients with direct CCF were younger age, associated with trauma, and more visual impairment at presentation. Chemosis, proptosis, bruit and dilated retinal vessels were detected more in the direct CCF than the dural CCF. Despite normal IOP, affected eyes had significantly higher IOP than the unaffected eyes. Information on these clinical characteristics may be helpful in discrimination of the direct type, which is more urgent for further investigation and treatment.

Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication?

Background

Flow diversion (FD) is an established treatment for large or giant wide-necked unruptured intracranial aneurysms. In the past few years, the use of flow diverter devices was extended to several other "off-label" indications, including solitary or adjunctive treatment to coil embolization for direct (Barrow A type) carotid cavernous fistulas (CCFs). The use of liquid embolic agents still represents the first-line treatment for indirect CCFs. Typically, the ipsilateral inferior petrosal sinus or superior ophthalmic vein (SOV) is the preferred transvenous routes to access CCFs. In some cases, vessel tortuosity or different features make the endovascular access challenging, thus requiring different approaches and strategies. The aim of the study is to discuss rational and technical aspect in treating indirect CCFs referring to the most up-to-date literature. An alternative experience-based endovascular strategy with FD is described.

Methods

We report the case of a 54-year-old woman diagnosed with indirect CCF and treated with flow diverter stent.

Results

After multiple unsuccessful attempts at transarterial right SOV catheterization, a right indirect CCF fed by a single trunk at the ophthalmic origin from the internal carotid artery (ICA) was treated by ICA stand-alone FD. Blood flow was redirect and successfully reduced through the fistula, with immediately postprocedure improvement of the patient's clinical status (ipsilateral proptosis and chemosis). Ten-months radiological follow-up showed the complete obliteration of the fistula. No adjunctive endovascular treatment was performed.

Conclusion

FD appears a reasonable alternative stand-alone endovascular strategy also for selected difficult-to-access indirect CCFs, when all conventional routes are judged unfeasible. Further investigations will be necessary to better define and support this potential lesson-learned application.

Hypercoagulability in patients with indirect carotid cavernous fistulas

BACKGROUND

To assess patients with indirect carotid-cavernous fistulas (CCF) for evidence of hypercoagulable state (HS) by combination of comprehensive medical questionnaire and laboratory testing.

METHODS

Patients with confirmed diagnosis of CCF treated between 2003 and 2019 were included and administered a questionnaire screening for HS risk factors and undergone laboratory investigations which included complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibody titres), Factor V Leiden, prothrombin, protein C, protein S, antithrombin III, homocysteine, prothrombin G20210, CALR and JAK2 mutation screening. Participants with abnormal laboratory testing and/or past history of ischemic stroke, atrial fibrillation, cancer or hypercoagulability-associated hereditary disorders were deemed to have HS.

RESULTS

Twenty-two patients were enrolled. Seventeen were women and the mean age at diagnosis was 60. Fourteen (64%) had evidence of HS: six on medical history, three with laboratory evidence and five with both. Eight (36%) had current abnormal hypercoagulability markers. One had a diagnosis of Klippel-Trenaunay Syndrome, but no others had evidence of hereditary thrombophilia. Nine were on anti-coagulation initiated after diagnosis of stroke or atrial fibrillation discovered on average 5.5 years after the diagnosis of CCF.

CONCLUSION

A total of 64% percent of patients with previous indirect CCF had evidence of underlying HS indicating that hypercoagulability might play a role in the pathogenesis of CCF. The results support need for comprehensive testing for underlying HS in patients with indirect CCFs to better identify, manage, and prevent further thromboembolic events.

De Novo dural arteriovenous fistulas after endovascular treatment: Case illustration and literature review

Intracranial dural arteriovenous fistulas (dAVF) account for nearly 10-15% of all arteriovenous malformations. Although the majority of dAVF are effectively cured after endovascular intervention, there are cases of dAVFs that may recur after radiographic cure. We present the case of a 69-year-old female with de novo formation of three dAVFs in different anatomic locations after successive endovascular treatments. The patient's initial dAVF was identified in the right posterior frontal convexity region and obliterated with transarterial and transvenous embolization. The patient returned eight years later due to left-sided pulsatile tinnitus and a new dAVF in the left greater sphenoid wing region was seen on angiography. This was treated with transvenous embolization with complete resolution. One year later, she developed left sided pulsatile tinnitus again and was found to have a left carotid-cavernous dAVF. This is the first case report to our knowledge of the formation of three de novo dAVFs over multiple years in distinct anatomical locations. We also review the literature regarding de novo dAVFs after endovascular treatment which includes 16 cases. De novo dAVF formation is likely due to numerous factors including changes in venous flow and aberrant vascular development. It is important to further understand the relationship between endovascular treatment and recurrent dAVF formation to prevent subsequent malformations.

Contemporary Management of Cranial Dural Arteriovenous Fistulas

Cranial dural arteriovenous fistulas (dAVFs) are rare acquired neurovascular disorders that have the potential to profoundly alter the local and global cerebral venous drainage. Factors such as location, angioarchitecture, degree of shunting, and mode of presentation all appear to have some bearing on the natural history of dAVFs, which can vary from almost entirely benign to life-threatening. Accurate and evidence-based risk stratification is, therefore, key to informing important management decisions. The treatment strategies are nuanced and, for an already rare entity, can vary tremendously from 1 fistula to another. It is only through a thorough understanding of their behavior and the treatment options available that we will be able to deliver tailored treatment to the correct dAVF and the correct patient. We aimed to provide an up-to-date summary of the reported data on the natural history and predictors of aggressive behavior for cranial dAVFs in general, followed by site-specific management considerations.

Case Report: Management of Traumatic Carotid-Cavernous Fistulas in the Acute Setting of Penetrating Brain Injury

Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options.

Clinical improvement in indirect carotid cavernous fistulas treated endovascularly: A patient based review

Patients with indirect carotid cavernous fistulas (CCF) were reviewed to emphasize the importance of diagnosing patients even with trivial findings and to raise awareness. Eighteen patients diagnosed as CCF were included. Neuro-ophthalmological findings before and after treatment, diagnostic investigations, treatment, clinical course was noted. Twelve patients were female (67%), 6 were males (33%) and the mean age at presentation was 54 years (range: 29-70 years). Conjunctival hyperemia was present in all patients. Seventeen (94%) patients had proptosis and diplopia, nine (50%) had orbital pain and/or headache, four (22%) had blurred vision, one (5.5%) had ptosis. On examination, 17 patients (94%) had restricted eye movements, four (22%) had low visual acuity and five patients had (28%) increased intraocular pressure (IOP). One patient had been diagnosed as myasthenia gravis and two as thyroid orbitopathy and had been on treatment accordingly before CCF was diagnosed. In two patients, bilateral findings were present despite unilateral CCF on angiography. Barrow Type B fistula was found in 7 (38%), Barrow Type D in 11 (62%) patients. In three bilateral CCF was detected. All were treated by endovascular intervention. Residual deficits at the sixth month control were, eye movement deficits in seven (39%), decrease in visual acuity in one (5.5%) and elevated IOP in one (5.5%) patient. Indirect CCF patients generally present with mild symptoms and the diagnosis may be overlooked. Mild progressive ophthalmoparesis with conjunctival hyperemia must be warning. Though rare bilateral CCF can be detected as well as unilateral CCF with bilateral findings.

Carotid Cavernous Fistula Treatment via Flow Diversion: A Systematic Review of the Literature

BACKGROUND

Carotid cavernous fistulas (CCFs) are pathologic connections between the carotid arteries and the cavernous sinus and have been classically treated with endovascular coil embolization, although flow diverters have been used for treatment successfully multiple times. The aim of this study is to systematically review the literature for efficacy of flow diverters in treating CCFs.

METHODS

A systematic review was conducted using the PRISMA guidelines. PubMed, PubMed Central, Cochrane Library, and Embase databases were searched. Combinations and variations of "carotid cavernous fistula," "flow diversion," "pipeline embolization device," "Surpass," "Silk," "p64," "FRED," and "flow redirection endoluminal device" in both AND and OR configurations were used to gather relevant articles. Citations of included articles from the systematic review were also screened for possible inclusion as a part of manual review. Included studies were full-text publications written in English that had patients with diagnosed CCFs and treatment with flow diversion.

RESULTS

Eighteen full-text publications were relevant to this systematic review. A total of 41 patients underwent flow-diverting therapy alone or in conjunction with coil embolization, liquid embolization, and/or stenting for treatment of a diagnosed CCF. Twenty-nine patients (70.7%) needed 1 procedure alone, 11 patients (26.8%) required a second procedure, and 1 patient (2.4%) required a third procedure. Six patients (14.6%) had lasting symptoms despite intervention; however, all 41 patients had clinical improvement compared with initial presentation. Flow diversion was a useful solitary treatment or adjunctive treatment in all patients.

CONCLUSIONS

Flow diversion is a useful adjunct in combination with coil embolization for the treatment of CCFs but long-term outcomes remain to be seen.

Central nervous system vascular malformations: A clinical review

CNS vascular malformation is an umbrella term that encompasses a wide variety of pathologies, with a wide range of therapeutic and diagnostic importance. This range spans lesions with a risk of devastating neurological compromise to lesions with a slow, static or benign course. Advances in neurovascular imaging along with increased utilization of these advances, have resulted in more frequent identification of these lesions. In this article, we provide an overview on definitions and classifications of CNS vascular malformations and outline the etiologic, diagnostic, prognostic, and therapeutic features for each entity. This review covers intracranial and spinal cord vascular malformations and discusses syndromes associated with CNS vascular malformations.

Traumatic cerebrovascular injury: clinical characteristics and illustrative cases

OBJECTIVE

Traumatic cerebrovascular injury (TCVI) is a rare and serious complication of traumatic brain injury (TBI). Various forms of TCVIs have been reported, including occlusions, arteriovenous fistulas, pseudoaneurysms, and transections. They can present at a variety of intervals after TBI and may manifest as sudden episodes, progressive symptoms, and even delayed fatal events. The purpose of this study was to analyze cases of TCVI identified at a single institution and further explore types and characteristics of these complications of TBI in order to improve recognition and treatment of these injuries.

METHODS

The authors performed a retrospective review of cases of TCVI identified at their institution between 2013 and 2016. A total of 5178 patients presented with TBI during this time period, and 42 of these patients qualified for a diagnosis of TCVI and had adequate medical and imaging records for analysis. Data from their cases were analyzed, and 3 illustrative cases are presented in detail.

RESULTS

The most common type of TCVI was arteriovenous fistula (86.4%), followed by pseudoaneurysm (11.9%), occlusion (2.4%), and transection (2.4%). The mortality rate of patients with TCVI was 7.1%.

CONCLUSIONS

The authors describe the clinical characteristics of patients with TCVI and provide data from a series of 42 cases. It is important to recognize TCVI in order to facilitate early diagnosis and treatment.

Cavernous sinus lesions

The cavernous sinus is a complex structure susceptible to a wide variety of vascular, neoplastic and inflammatory pathologies. Vascular pathologies include ICA aneurysms, carotid-cavernous fistulas, cavernous sinus thrombosis, and cavernous hemangioma. Neoplasms that involve the cavernous sinus include pituitary adenoma, meningioma, schwannoma, lymphoma, perineural tumor spread, metastases, and direct tumor invasion. Infectious and inflammatory diseases include Tolosa-Hunt syndrome, sarcoidosis, granulomatosis with polyangiitis, IgG-4 related disease and invasive fungal infections. In this article, we review the clinical and imaging findings of a number of pathologies involving the cavernous sinus, focusing on key features that can narrow the differential diagnosis and, in some cases, support a particular diagnosis.

Embolization of carotid-cavernous fistulas: A technical note on simultaneous balloon protection of the internal carotid artery

A carotid-cavernous fistula (CCF) is an abnormal connection between the carotid circulation and the cavernous sinus. Treatment of CCFs often consists of obliteration of the fistula by a transarterial or transvenous endovascular approach using embolic agents. However, fistula embolization is often halted due to the potential embolic complications that may arise from the retrograde flow of the embolic agents into the arterial circulation, which often leads to the development of fistula recurrence. Moreover, retreatment of a CCF recurrence is challenging and more complex approaches may be required. In this technical note, we describe our experience with CCF embolization in 25 patients treated at a single center. We utilized a transvenous approach for CCF embolization with simultaneous balloon occlusion of the internal carotid artery during the infusion of the embolic material into the fistula. In our series, this simultaneous protection of the internal carotid artery showed to be a safe technique to prevent embolic complications and to achieve successful obliteration of the fistula. On follow-up, 2 cases presented a recurrence, one due to technical difficulties and the other related to an undetected vascular injury. In conclusion, this technique provides a safe approach in the treatment of CCFs by decreasing the risk of embolic complications and increasing the effectiveness of the embolic agents in accomplishing the obliteration of the CCF.

Iatrogenic Direct Carotid-cavernous Fistula Following Mechanical Thrombectomy: A Case Report and Review of the Literature

A carotid-cavernous fistula (CCF) is an abnormal connection between the arteries and veins of the cavernous sinus. Iatrogenic CCFs have been described as potential complications following aneurysm coiling, balloon angioplasty, and transsphenoidal surgery. In this case report, we describe a rare case of an iatrogenic direct CCF following mechanical thrombectomy (MT) for acute ischemic stroke. A 78-year-old female presented to an outside hospital with a new onset of right-sided weakness and aphasia and underwent emergency MT for a left middle cerebral artery (MCA) occlusion. The procedure was complicated by iatrogenic injury to the left cavernous internal carotid artery (ICA), which resulted in a direct high-flow CCF. The patient was transferred to our hospital and the fistula was closed with transarterial coils. Ten days later, she returned with diplopia and cranial nerve VI palsy due to residual pseudoaneurysm and was treated with a flow-diverting stent. On follow-up, the patient was neurologically intact and imaging showed no residual fistula. As the frequency of MTs performed for acute ischemic stroke continues to rise, neurointerventionalists should be aware of this potential rare complication and be prepared to manage patients who develop symptomatic CCF.

Spontaneous Closure of a Cavernous Sinus Dural Arteriovenous Fistula with Spinal Perimedullary Drainage (Cognard V) during Attempted Transvenous Embolization

The authors describe a patient with spontaneous closure of a spontaneous cavernous sinus dural arteriovenous fistula (CSDAVF), Cognard type V, during transvenous attempt. A 39-year-old woman experienced mild proptosis, redness of the left eye, and diplopia. Four months later, she developed left retro-orbital pain and left-sided headache. Cerebral angiography revealed the left CSDAVF exclusively draining into the superior petrosal sinus with subsequent drainage into the veins surrounding the medulla oblongata, and finally into the perimedullary spinal veins, classified as Cognard type V. The feeders arise from the dural branches of both the left external and internal carotid arteries. Following 2 h period of attempted transvenous embolization, the fistula disappeared spontaneously. Follow-up angiography obtained 6 months later confirmed complete resolution of the CSDAVF. At 2-year follow-up, the patient has remained clinically asymptomatic. The mechanism of thrombosis in this fistula related to the endovascular procedure. We speculated that putting the wire tip in the draining vein may induce the spontaneous thrombosis in the venous side. In addition, precipitating factors may include small, low-flow fistula, and pre-existing thrombosis.

Direct carotid-cavernous fistula: an atypical presentation

Posttraumatic carotid-cavernous fistula (CCF) is a very rare complication that can occur in patients with craniomaxillofacial trauma. It is defined by abnormal communication between arteries and veins located in the cavernous sinus. CCFs can be divided into two groups: direct, which are usually post traumatic and classically with a high flow and acute onset of symptoms. On the other hand, indirect CCFs are in the most of cases idiopathic and typically insidious of onset. The aim of the present case report is to describe an atypical presentation of direct CCF characterized by the insidious onset of symptoms with the goal to think about this rare complication and so not to delay the treatment which is an emergency in this case.

Transarterial and transvenous access for neurointerventional surgery: report of the SNIS Standards and Guidelines Committee

The purpose of this publication is to provide a comprehensive review on the techniques and tools used for vascular access in neurointerventional procedures. Using published literature, we reviewed data on access methods, sites, tools, and techniques for neurointerventions. Recommendations are provided based on quality of data/levels of evidence and, where appropriate, expert consensus. While tools and techniques continue to be developed, current literature and experience supports certain principles regarding vascular access for neurointerventional procedures.

Internal carotid artery occlusion may affect long-term quality of life in patients with high-flow carotid cavernous fistulas

PURPOSE

To investigate the mid- and long-term effects of parent artery occlusion on the carotid cavernous fistula and on the quality of life of patients.

MATERIALS AND METHODS

One hundred and twenty-six patients with high-flow direct carotid cavernous fistulas were enrolled. The modified Rankin scale scores, the headache impact test and the short form health survey scores were used to evaluate the patients' clinical status.

RESULTS

Fifty-two patients had parent artery occlusion, while the rest of the 74 patients had embolization of carotid cavernous fistulas with parent artery preservation. No periprocedural complications occurred. Eighteen patients in the parent artery occlusion group had low perfusion symptoms within two weeks following embolization, and three patients had Horner's syndrome on the ipsilateral side. At two months' follow-up, the patients with parent artery occlusion had a significantly (P < 0.05) greater proportion of headache than patients with parent artery preservation. At 12 months, no significant (P > 0.05) difference existed in the headache impact test scores in both groups. At 36 months' follow-up, the patients with parent artery occlusion had decreased SF-30 scores in all the eight health domains compared with patients treated with parent artery preservation, with a significant (P < 0.05) lower score in general health, vitality and bodily pain in the parent artery occlusion compared with the parent artery preservation group. No recurrence was shown in patients with parent artery occlusion, but nine (12.2%) patients were recurrent in patients with parent artery preservation.

CONCLUSION

Parent artery occlusion may affect the quality of life of patients with carotid cavernous fistulas despite being an effective treatment option for high-flow direct fistulas.

Neuroradiological and clinical features in ophthalmoplegia

PURPOSE

Especially in acute onset of ophthalmoplegia, efficient neuroradiological evaluation is necessary to assist differential diagnosis, clinical course, and treatment options.

METHODS

Different manifestations of ophthalmoplegia are explained and illustrated by characteristic neuroradiological and clinical findings.

RESULTS

To present those ophthalmoplegic disorders in a clear manner, this review refers to different neuroanatomical structures and compartments. From neuroophthalmological point of view, diseases going ahead with ophthalmoplegia can be divided into (1) efferent infranuclear/peripheral disturbances involving oculomotor cranial nerves, (2) conjugate gaze abnormalities due to internuclear or supranuclear lesions, and (3) diseases of the extraocular eye muscles or their impairment due to intraorbital pathologies.

CONCLUSION

The knowledge of the relationship between neurological findings in ophthalmoplegia and involved neuroanatomical structures is crucial, and neuroradiology can be focused on circumscribed anatomical regions, using optimized investigation protocols.

Endovascular treatment of carotid-cavernous sinus fistulas: ophthalmic and visual outcomes

Purpose: The main objective was to report the epidemiology, clinical manifestations, angiography features, treatment modality and post-treatment outcomes in patients diagnosed with carotid cavernous fistulas (CCF). Methods: A retrospective review of the medical imaging database in conjunction with medical records from 2004 to 2017 at the Royal Brisbane and Women's Hospital (RBWH) was conducted.We identified 39 patients with CCF (16 direct, 23 indirect). A total of 37 diagnoses were confirmed by direct catheter angiography. The remaining two cases were diagnosed using magnetic resonance imaging/magnetic resonance angiography. Results: Coils were deployed in 100% of direct and 83% of treated indirect fistulas that were treated. Other embolic agents were deployed alone or in combination with coils. Successful angiographic closure was achieved in 93% of direct and 92% of indirect fistulas. Multiple treatments were required in 33% of direct and 16% of indirect fistulas. Visual acuity improved in patients with direct fistulae(p = 0.02) and was preserved in those with indirect fistulae. Post-treatment diplopia persisted in six patients with direct fistulas and three patients with indirect fistulas. Four patients with indirect fistulas experienced persistent ocular hypertension post-treatment compared to two patients with direct fistulas. Conclusions: Endovascular coils are the most commonly deployed treatment for CCF. Both indirect and direct fistulas achieved high rates of closure; however, indirect fistulas were less likely to require multiple treatments. Good post-procedural vision was achieved for both groups.

Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms

Background

Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms.

Summary

We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period.

Key Message

Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.

Post-traumatic right carotid-cavernous fistula resulting in symptoms in the contralateral eye: a case report and literature review

Background

To report a case of a carotid-cavernous fistula (CCF) that occurred after a motor vehicle accident and review the uniqueness of this case and the main confusing points for the diagnosis of such cases.

Case presentation

A 22-year-old man complained of left eyelid swelling, eye redness, visual decrease and occasional headache after motor vehicle accident 4 months prior during which he experienced a head injury. He was initially thought to have glaucoma, but he was finally diagnosed with a right CCF based on magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). Timely embolization surgery resulted in obvious relief of the ocular symptoms and an improved prognosis.

Conclusion

This is the first reported case of a post-traumatic unilateral CCF with contralateral symptoms in direct CCF, it is very infrequent and deserves our attention. We should maintain high suspicion of CCF and confirm the diagnosis by DSA when managing such patients to prevent serious consequences. Early diagnosis and treatment can improve the prognosis of patients.

A rare case of bilateral spontaneous indirect caroticocavernous fistula treated previously as a case of conjunctivitis

Carotid cavernous fistula is an abnormal communication between the carotid arterial system and the cavernous sinus. We present an interesting, rare case of bilateral spontaneous ‘Barrow type- C’ fistula treated presumptively as conjunctivitis. A 66 year old patient presented in the eye casualty at North Devon District Hospital in January 2016, referred from her General practitioner complaining of bilateral red eyes. She was found to have large, prominently diffused and engorged scleral blood vessels on both sides along with raised intraocular pressures of 26mm of Hg bilaterally. The patient was diagnosed with an indirect carotic cavernous fistulas bilaterally in view of the clinical and radiology findings. Barrow type - C dural fistulas were reported to be seen bilaterally on radiology findings. Patient was referred for interventional treatment to the closest neurosurgical center where she had four failed attempts of coil embolization after which she was referred to a second neurosurgery center at Bristol where she underwent successful coil catheterization as the treatment for her carotid cavernous fistula. Indirect carotid cavernous fistula most commonly occur spontaneously. Bilateral spontaneous indirect carotid cavernous fistula is a very rare diagnosis and and there are very few cases reported in the literature without an underlying etiology or a known cause like Ehlers -Danlos syndrome or diabetes mellitus. Bilateral spontaneous carotid cavernous fistulas are difficult to diagnose due to mild symptoms and no history of trauma. We conclude that carotid cavernous fistulas are a threat to the vision if left untreated due to delayed diagnosis. We recommend considering bilateral carotid cavernous fistula as a differential diagnosis in patients with an ongoing history of red eyes or those unresponsive to conventional topical treatment for conjunctivitis like symptoms.

Orbital apex disorders: Imaging findings and management

Orbital apex disorders include orbital apex syndrome, superior orbital fissure syndrome and cavernous sinus syndrome. These disorders result from various etiologies, including trauma, neoplastic, developmental, infectious, inflammatory as well as vascular causes. In the past, these have been described separately based on anatomical locations of disease process; however, these three disorders share similar causes, diagnostic evaluation and management strategies. The etiology is diverse and management is directed to the causative process. This imaging review summarizes the pertinent anatomy of the orbital apex and illustrates representative pathological processes that may affect this region. The purpose of this review is to provide an update on the current status of diagnostic imaging and management of patients with orbital apex disorders.

Imaging findings and outcomes in patients with carotid cavernous fistula at Inkosi Albert Luthuli Central Hospital in Durban

Background

Carotid cavernous fistulas (CCFs) are relatively uncommon and are difficult to diagnose clinically. Radiological imaging plays a significant role in making the diagnosis with recent advances improving the ability of radiologists to diagnose the condition. Despite these developments, digital subtracted angiography (DSA) remains the gold standard in diagnosing CCFs and simultaneously provides the opportunity for intervention.

Objectives

To determine the imaging findings of patients presenting to Inkosi Albert Luthuli Central Hospital (IALCH) with a CCF and to assess the outcome of endovascular intervention.

Method

We reviewed the electronic records and archived imaging data of consecutive patients diagnosed with CCF between January 2003 and May 2016 at IALCH, in particular, the imaging findings, intervention and subsequent outcomes.

Results

Computed tomography (CT) was the most utilised imaging modality prior to patients undergoing DSA. A dilated superior ophthalmic vein (96%) was the most prevalent imaging finding on axial imaging. At DSA, all except two patients had high-flow fistulas. The fistulas predominantly drained anteriorly (69.44%) and a cavernous internal carotid artery aneurysm was identified in eight patients. Occlusion of the fistula was attained in all patients that were compliant with follow-up and underwent intervention (n = 36, 100%), but parent artery sacrifice was required in 10 cases (27.78%).

Conclusion

A wide range of imaging modalities can be used in the workup of a CCF. CT is currently the most accessible modality in our setting, with limited access to magnetic resonance imaging. On axial imaging, a dilated superior ophthalmic vein is the commonest finding. Classification of a fistula according to flow dynamics and noting the presence of aneurysms or pseudoaneurysms was found to be more practical in comparison to the traditional Barrow’s classification. Management outcomes at our institution compare well with available local and international data.

A Case of Right-Sided Direct Carotid Cavernous Fistula: A Diagnostic Challenge

Patient: Female, 83

Final Diagnosis: Right-sided direct carotid cavernous fistula

Symptoms: Chemosis • proptosis and eye pain

Medication: Topical α2-adrenergic agonist

Clinical Procedure: Endovascular embolization

Specialty: Internal Medicine • Interventional Radiology • Ophthalmology

Spontaneous Bilateral Carotid-Cavernous Fistulas Secondary to Cavernous Sinus Thrombosis

Bilateral carotid cavernous fistulas are rare entities that can cause debilitating symptoms and can lead to more severe consequences if left untreated. Therefore, the recognition and adequate treatment of these pathologies is very important. We present 2 cases of bilateral carotid cavernous fistulas that arose as a result of cavernous sinus thrombosis. We review the literature and discuss the pathophysiology, symptomatology, management, and treatment of bilateral carotid cavernous fistulas. Within our own cases, treatment of the patients was varied. The patient in case 1 was successfully treated with endovascular therapy after a failed trial of anticoagulation. The patient in case 2 demonstrated resolution of bilateral carotid cavernous fistulas after anticoagulation therapy. Case 2 highlights the fact that certain cases of bilateral carotid cavernous fistulas due to cavernous sinus thrombosis may benefit from extensive anticoagulation therapy. If anticoagulation therapy is unsuccessful, endovascular therapy may prove beneficial in resolving the fistulous shunt.

A rare case report of complications in craniofacial injuries: Cavernous sinus-carotid fistula

RATIONALE

Cavernous sinus-carotid fistula (CCF) is a rare complication of craniofacial injuries in patients receiving oral and maxillofacial surgical care.

PATIENT CONCERNS

A retrospective review of 15 patients with CCF records was conducted. In addition, we present a rare case of a 32-year-old Chinese woman with CCF receiving oral and maxillofacial surgical care.

DIAGNOSES

Digital subtraction angiography (DSA) confirmed a diagnosis of CCF.

INTERVENTIONS

Endovascular surgery was performed via the femoral artery under general anesthesia without any complications.

OUTCOMES

The postoperative course was uneventful, and the subjective and objective ophthalmic symptoms had resolved.

LESSONS

The symptoms of CCF may be delayed for several days or weeks. Thus, maxillofacial surgeons should be aware of this and avoid the untimely repair of facial fractures with potentially disastrous consequences. Interventional neuroradiologic approaches that involve the use of a detachable balloon have made it possible to care for patients with CCF without any complications.

Treatment of Barrow type 'B' carotid cavernous fistulas with flow diverter stent (Pipeline)

Background Carotid cavernous fistulas (CCFs) Barrow type 'B' are dural shunts between the meningeal branches of the internal carotid artery and the cavernous sinus. The symptoms include vision deterioration, ophthalmoplegia with diplopia, exophthalmos, conjunctival injection, chemosis, ocular bruit, seizures, or neurological deficit. Endovascular treatment remains the gold standard for treatment through the transvenous or transarterial routes. The transvenous approaches have been proved to be the first option. Endovascular access through the superior ophthalmic vein (SOV) or inferior petrosal sinus have been widely used. The problem arises when there is no vascular access. For these cases, different approaches have been described, such as: direct access to the SOV; combining direct access to the SOV along with blind probing of the proximal occluded SOV; and a direct puncture of the cavernous sinus. But these techniques are very aggressive and can cause serious complications. As a result of the above, we describe a new alternative technique, which is effective and less invasive for the treatment of these special cases. Case reports We report two cases of Barrow type 'B' CCFs that did not have vascular access (neither arterial nor venous) to embolise fistulas with coils or glue, and which were successfully resolved with a flow diverter (Pipeline) stent in the internal carotid artery. To our knowledge, this treatment has not previously been described for this pathology. Conclusions The placement of a flow diverter stent in the internal carotid artery is an effective alternative technique in those cases of Barrow type 'B' CCFs that have no vascular access (neither venous nor arterial).

Carotid-Cavernous Fistula as a Complication of Panfacial Fracture: Case Report 11 Years after the Surgery

The carotid-cavernous fistula (CCF) is a rare complication in patients victimized by craniofacial trauma. It involves multidisciplinary medical action. Owing to its potential complications, it is essential that maxillofacial surgery and neurosurgery specialists diagnose this condition so that appropriate treatment can be performed. The authors present a report of a case 11 years after the surgery.

Neurovascular emergencies: imaging diagnosis and neurointerventional treatment

Neurovascular emergencies, consisting of acute ischemic stroke, non-traumatic aneurysmal subarachnoid hemorrhage, arteriovenous malformation, dural arteriovenous fistula, and carotid- cavernous fistula, can have an acute presentation to the emergency department. Radiologists should have an understanding of these processes and their imaging findings in order to provide a prompt and accurate diagnosis. Neurointerventional radiology plays a critical role in providing additional diagnostic information and potentially curative treatment. Understanding the grading scales used to evaluate and prognosticate these neurovascular emergencies can help expedite management for best possible patient outcomes.