Endovascular Treatment of Carotid Cavernous Fistulas

Carotid-cavernous fistula: A potential treatable cause of bilateral abducens palsy and conjunctival hyperemia

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.

Natural course of partially embolized carotid-cavernous fistulas

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.

Transvenous embolization of noncavernous dural arteriovenous fistulas (dAVFs): A systematic review and meta-analysis

BACKGROUND

Intracranial dural arteriovenous fistulas (dAVFs) are abnormal connections between arteries and veins within the dura mater. Various treatment modalities, such as surgical ligation, endovascular intervention, and radiosurgery, aim to close the fistulous connection. Although transvenous embolization (TVE) is the preferred method for carotid-cavernous fistulas, its description and outcomes for noncavernous dAVFs vary. This has prompted a systematic review and meta-analysis to comprehensively assess the effectiveness of TVE in treating noncavernous dAVFs, addressing variations in outcomes and techniques.

METHODS

We searched PubMed and Embase, spanning from the earliest records to December 2022, to identify pertinent English-language articles detailing the utilization of TVE. We focused on specific procedural details, outcomes, and complications in patients older than 18 years. The data collected and analyzed comprised the sample size, number of fistulas, publication specifics, presenting symptoms, fistula grades, and pooled rates of embolizations, outcomes, follow-up information, and complications.

RESULTS

From a total of 565 screened articles, 15 retrospective articles encompassing 166 patients spanning across seven countries met the inclusion criteria. Their Newcastle-Ottawa scores ranged from 6 to 8. Intraprocedural complication rate was 10% (95% confidence interval [CI] = 5.9-17.1) and in-hospital postprocedural complication rate was 5.4% (95% CI = 2.8-10.6). Prevalence of in-hospital mortality was 5.5% (95% CI = 2.9-10.6). Complication rate during follow-up was 8.6% (95% CI = 4.7-15.7) with fistula rupture occurring in 5.5% (95% CI = 2.6-11.6) of patients. Complete obliteration rate at final angiographic follow-up was 94.9% (95% CI = 90.3-99.9). Symptoms improved in 95% (95% CI = 89.8-100) of patients at final follow-up.

CONCLUSION

To our knowledge, we present the first meta-analysis assessing obliteration rates, outcomes, and complications of TVE for dAVFs. Our analysis highlights the higher (>90%) complete obliteration rates. Large prospective multicenter studies are needed to better define the utility of TVE for noncavernous dAVFs.

Hypoglossal Canal Dural Arteriovenous Fistula: A Rare Cause of Ocular Proptosis

It is exceedingly rare for dural arteriovenous fistulae (DAVFs) outside of the cavernous sinus to present with ophthalmological symptoms and signs. Hypoglossal canal DAVFs (HC-DAVFs) have only previously been reported as individual cases or small case series. Further, only an estimated 31% of HC-DAVFs present with ophthalmological findings. We report a noteworthy case of an HC-DAVF in a 74-year-old male who presented with proptosis, chemosis, and reduced visual acuity. He was treated endovascularly with liquid embolic filling. This report aims to highlight HC-DAVF as an important differential diagnosis for patients presenting with symptoms suggestive of arterialisation of the ophthalmic veins.

Off-label use of large diameter Concerto fibered coils through a 0.017 inch microcatheter for transvenous embolization of indirect carotid-cavernous fistulas: two case reports

BACKGROUND

A carotid-cavernous fistula is an abnormal communication between the arteries and veins within the cavernous sinus. While conservative management may be prudent in low risk cases, many patients require intervention and endovascular embolization has evolved as the preferred method of treatment. Embolization can be performed via either the transarterial or transvenous approach. One major challenge of the transvenous approach is the complex and variable compartmentation of the cavernous sinus, which often requires the use of low profile microcatheters to navigate and reach the fistulous point. Fibered coils are also preferred when performing transvenous embolization of carotid-cavernous fistula, as they are of higher thrombogenicity and allow for faster occlusion of the fistula. However, most low profile (0.017-inch) microcatheters are not able to deploy fibered coils based on the manufacturer's instructions.

CASE PRESENTATION

We present two successful cases of off-label use of Medtronic Concerto fibered coils via a 0.017-inch microcatheter during transvenous embolization of carotid-cavernous fistula in a 60-year-old and an 80-year-old Chinese female, respectively.

CONCLUSION

Our case series highlight the possibility of deploying large diameter (up to 10 mm) Concerto fibered coils through a low profile (0.017-inch) microcatheter in an off-label manner for transvenous embolization of indirect carotid-cavernous fistula.

Indications for alternative endovascular techniques in carotid-cavernous fistulas: A 20-year single-center experience

BACKGROUND

While coiling is considered the standard treatment for carotid-cavernous fistulas (CCFs), studies demonstrating excellent results using new materials, especially flow diverter (FD) stents and liquid embolisates, are becoming more frequent. The indications and effectiveness of these alternative endovascular techniques remain unclear.

METHODS

A total of 22 direct and 20 indirect CCFs were included in the study. These were further subdivided based on the embolic material used: coils versus FD stents for direct and coils versus liquid embolisates for indirect CCFs. The subgroups were subjected to statistical analysis.

RESULTS

An angiographic cure was achieved in 88% of all CCFs, 93% of patients' experienced clinical improvement or remained stable. Direct CCFs were treated with coiling (41%) or with both coils and FD stents (55%). One (4%) patient with a direct CCF was treated with FD stent alone. Statistical analysis comparing these subgroups revealed a significantly higher complete occlusion rate immediately after treatment in the coiling subgroup (67% vs. 23%, p = 0.0409). The occlusion rates at the last follow-up were similar (89% vs. 85%). Indirect CCFs were treated with coiling (35%) or liquid embolisates (65%). All three periprocedural ischemic complications were recorded within the liquid subgroup, resulting in a significantly higher clinical deterioration rate (p = 0.0333).

CONCLUSION

FD stents in direct and liquid embolisates in indirect fistulas did not demonstrate better angiographic or clinical outcomes compared to convetional coiling. Liquid agents carried a higher risk of ischemic complications. Alternative embolization materials should be reserved for CCFs that cannot be treated with simple coiling.

Operative Cannulation of the Superior Ophthalmic Vein for Embolization of Cavernous Sinus Dural Arteriovenous Fistulas: Surgical Techniques and Clinical Outcomes

BACKGROUND

Endovascular therapy is the first-line treatment for the cavernous sinus dural arteriovenous fistulas, particularly transvenous embolization. This study aimed to assess the trans-superior ophthalmic vein approach to embolization for its safety, efficacy, and viability as a first-line treatment in selected patients, with a description of the microsurgical and endovascular techniques.

METHODS

We retrospectively reviewed patients with cavernous sinus dural arteriovenous fistulas treated using the direct superior ophthalmic vein approach with n-butyl cyanoacrylate and coils as the main embolic materials from 2015 to 2021. The safety and efficacy of the treatment were evaluated based on ocular and neurological improvement, angiographic obliteration, and recurrence.

RESULTS

Of the 16 patients, all cases were diagnosed with cavernous sinus dural arteriovenous fistulas. The n-butyl cyanoacrylate was used as the sole embolic material in 12 cases, and coils were used in 4 cases. A direct superior ophthalmic vein approach was selected as the first option in 11 patients. All the patients achieved complete fistula obliteration and good recovery from ocular symptoms, accompanied by excellent cosmetic results. No recurrence was observed at a mean follow-up period of 26 months.

CONCLUSIONS

Microsurgical dissection for exposure and direct cannulation of the superior ophthalmic vein as a route for fistula obliteration delivers excellent clinical outcomes, with a low rate of complications. Not only is it safe and effective as an alternative approach but it can also serve as first-line treatment in selected patients.

First reported single-surgeon transpalpebral hybrid approach for indirect cavernous carotid fistula: illustrative case

BACKGROUND

Failure to reach the cavernous sinus after multiple transvenous attempts, although rare, can be challenging for neurointerventionists. The authors sought to demonstrate technical considerations and nuances of the independent performance of a novel hybrid surgical and endovascular transpalpebral approach through the superior ophthalmic vein (SOV) for direct coil embolization of an indirect carotid cavernous fistula (CCF), and they review salient literature regarding the transpalpebral approach.

OBSERVATIONS

An illustrative case, including patient history and presentation, was reviewed. PubMed, MEDLINE, and Embase databases were searched for articles published between January 1, 2000, and September 30, 2021, that reported ≥1 patient with a CCF treated endovascularly via the SOV approach. Data extracted included sample size, treatment modality, surgical technique, performing surgeon specialty, and procedure outcome. The authors’ case illustration demonstrates the technique for the hybrid transpalpebral approach. For the review, 273 unique articles were identified; 14 containing 74 treated patients fulfilled the inclusion criteria. Oculoplastic surgery was the most commonly involved specialty (5 of 14 studies), followed by ophthalmology (3 of 14). Coiling alone was the treatment of choice in 12 studies, with adjunctive use of Onyx (Medtronic) in 2.

LESSONS

The authors’ technical case description, video, illustrations, and review provide endovascular neurosurgeons with a systematic guide to conduct the procedure independently.

A Case of Spontaneous Bilateral Direct Carotid-Cavernous Fistula

A 92-year-old female with poorly controlled systemic hypertension presented with bilateral eye redness, lid fullness, conjunctival chemosis, ophthalmoplegia, and ptosis for two days. A neuro-ophthalmic evaluation revealed bilateral proptosis, severe conjunctival chemosis and congestion, and an almost complete bilateral ophthalmoplegia with a complete right superior eyelid ptosis. Computed tomography (CT) scans demonstrated bilateral dilation of the superior ophthalmic veins, and a CT angiography (CTA) showed a direct high-flow carotid-cavernous fistula (CCF) with secondary extraocular muscle enlargement. Clinicians should be aware that a typical direct high-flow CCF, although usually occurs after trauma and unilaterally, can present spontaneously without trauma and bilaterally.

A Case of Direct Carotid-Cavernous Fistulae Successfully Treated by Bidirectional Double Catheter Technique: A Technical Note

Objective

Ruptured carotid-cavernous aneurysms (CCAs) are known to result in direct carotid-cavernous fistula (CCF). Although endovascular treatment is recognized as the first-line treatment for direct CCF, obliteration is sometimes difficult because of the high-flow shunt. In this report, we present a case of a direct CCF treated by the combination of transarterial and transvenous approaches.

Case Presentation

A 57-year-old woman presented with conjunctival chemosis, exophthalmos, and tinnitus. Ophthalmological examination revealed increased intraocular pressure. DSA demonstrated a direct CCF due to a right ruptured CCA with retrograde shunted flow through the superior ophthalmic vein (SOV), superficial middle cerebral vein, basal vein of Rosenthal, and middle temporal vein. Two microcatheters were guided into the shunt segment from the internal carotid artery and SOV. In addition, a balloon catheter was placed at the neck of the aneurysm to assist coiling. Coil embolization for the CCF was performed using two microcatheters in the opposite direction, which enabled compact and tight packing of the shunt segment with only six coils. The CCF was eliminated. Two-year-follow-up MRA revealed no recurrence.

Conclusion

The bidirectional double catheter technique is a useful approach to obliterate a shunt in a short segment with minimal coils.

Long-term stability of Onyx: is there any indication for repeated angiography after dural arteriovenous fistula embolization?

OBJECTIVE

The natural course of dural arteriovenous fistulas (DAVFs) is unfavorable. Transarterial embolization with Onyx is currently the therapeutic method of choice, although the long-term stability of Onyx has been questioned. The literature reports a significant difference in the recurrence rate after complete DAVF occlusion and lacks larger series with long-term follow-up. The authors present the largest series to date with a long-term follow-up to determine the stability of Onyx, prospectively comparing magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) as follow-up diagnostic methods.

METHODS

Demographics, clinical symptomatology, length of follow-up, diagnostic methods, and angiographic findings of DAVFs were recorded and retrospectively evaluated in 112 patients. A prospective group of 15 patients with more than 5 years of follow-up after complete DAVF occlusion was established. All 15 patients in the prospective group underwent a clinical examination and MRA; 10 of these patients also underwent DSA. The recurrences and the correlation between the two diagnostic methods were evaluated.

RESULTS

Among the 112 patients, 71 were men and 41 were women, with an average age of 60 years. Intracranial hemorrhage (40%) was the most common clinical presentation of DAVF. At the last follow-up, 73% of the patients experienced clinical improvement, 21% remained unchanged, and 6% worsened. Overall, 87.5% of the DAVFs were occluded entirely with endovascular treatment, and 93% of the DAVFs were classified as cured at the last follow-up (i.e., completely embolized DAVFs and DAVFs that thrombosed spontaneously or after Gamma Knife surgery). Two recurrences of DAVFs were recorded in the entire series. Both were first diagnosed by MRA and confirmed with DSA. The mean follow-up was 27.7 months. In the prospective group, a small asymptomatic recurrence was diagnosed. The mean follow-up of the prospective group was 96 months.

CONCLUSIONS

Onyx is a stable embolic material, although recurrence of seemingly completely occluded DAVFs may develop because of postembolization hemodynamic changes that accentuate primarily graphically absent residual fistula. These residuals can be diagnosed with MRA at follow-up. The authors' data suggest that MRA could be sufficient as the follow-up diagnostic method after complete DAVF occlusion with Onyx. However, larger prospective studies on this topic are needed.

Carotid cavernous fistula (CCF) treatment approaches: A systematic literature review and meta-analysis of transarterial and transvenous embolization for direct and indirect CCFs

BACKGROUND

Carotid Cavernous Fistulas (CCFs) are the result of an abnormal communication between the carotid artery and its branches and the venous system of the cavernous sinus. The mainstay of therapy for CCFs consists of transarterial or transvenous embolization, while other treatment options such as open surgery or radiosurgery are still utilized as second-line or adjuvant therapeutic options.

OBJECTIVE

Our aim was to systematically review and summarize available data regarding short- and long-term outcomes of all available treatment modalities for CCFs.

METHODS

This systematic review was conducted according to the PRISMA guidelines. A random effects model meta-analysis was conducted.

RESULTS

Fifty-seven studies comprising 1575 patients were included in this systematic review. Transarterial embolization for direct and indirect CCFs offered a complete obliteration rate of 93.93% (N = 589/627) and 81.51% (N = 119/146), respectively. Transvenous embolization for direct and indirect lesions achieved obliteration in 91.67% (N = 33/36) and 86.03% (N = 425/494) of patients, respectively. Comparison between transarterial and transvenous embolization did not reveal statistically significant differences in terms of fistula obliteration for direct (OR: 1.42; 95% CI: 0.23-8.90; I² 0.0%) and indirect CCFs (OR: 0.62; 95% CI: 0.31-1.23; I² 0.0%).

CONCLUSIONS

Endovascular embolization techniques are the preferred treatment modality for the management of CCFs. No differences were identified between transarterial and transvenous embolization by synthesizing studies with available data. Future prospective cohorts are warranted to compare the different materials and techniques implemented especially within the rapidly expanding realm of endovascular approaches.

Is the retrograde access for endovascular treatment of a traumatic carotid cavernous fistula associated with dissection of the ipsilateral carotid possible?

This is a case demonstrating a combined traumatic lesion of the internal carotid artery (dissection and a carotid cavernous fistula [CCF]) in a patient who was beaten during a robbery and, while trying to escape, was hit by a vehicle. Endovascular approach for the treatment was chosen using the retrograde access from the vertebral artery to the cavernous sinus by posterior communicating (Pcom) artery due to the occlusion of the ipsilateral internal carotid. Because the artery access by the internal carotid was impossible, retrograde approach by vertebral artery and Pcom artery was done to treat the direct CCF. A patient presented with left hemiplegia and proptosis, chemosis, right eye ptosis. Computed tomography (CT) and CT angiography revealed a CCF of the right carotid. An arterial retrograde endovascular approach by the vertebral artery was used for CCF occlusion with coils. We present a rare case of a combined traumatic cerebrovascular lesion, right carotid artery dissection and a right direct CCF treated by a retrograde endovascular approach by the vertebral artery through the Pcom artery to reach the fistula point and achieved a complete cure of the CCF.

Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, and Carotid Cavernous Fistulas

Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.

Multimodal Management of Carotid-Cavernous Fistulas

BACKGROUND

Techniques for endovascular management of carotid-cavernous fistulas (CCFs) have evolved over the years. Current strategies include transarterial or transvenous approaches and direct puncture or exposure of the cavernous sinus. Rarely, complex CCFs may require multiple approaches or procedures. We describe our experience managing CCFs, reporting on outcomes and technical nuances.

METHODS

A retrospective review of institutional records was conducted to identify consecutive cases of CCF treated between July 2005 and July 2016. Pertinent technical details and outcomes were recorded.

RESULTS

In 44 patients, 51 procedures were performed. There were 13 direct CCFs and 31 indirect CCFs: 13 (30%) type A, 3 (7%) type B, 5 (11%) type C, and 23 (52%) type D. A transarterial approach was selected in 39% of cases (n = 20), resulting in a long-term successful embolization rate of 60% (n = 12). Transvenous methods via the inferior petrosal sinus or superior ophthalmic vein were used in 49% of cases (n = 25), resulting in a long-term obliteration rate of 88% (n = 22). Multimodal management was required in 5 patients, including 1 patient in whom a craniotomy was performed to facilitate coil embolization of the cavernous sinus under direct vision. A 7% complication rate (n = 3) was observed, with significant morbidity in 1 patient.

CONCLUSIONS

CCFs are complex vascular lesions that require facility with various endovascular and surgical approaches. High-flow, direct-type fistulas may harbor a significant risk of recurrence after transarterial embolization. Partial or unsuccessful embolization may necessitate an open surgical approach to the superior ophthalmic vein or cavernous sinus.

Treatment Outcomes According to Various Treatment Modalities for Intracranial Dural Arteriovenous Fistulas in the Onyx Era: A 10-Year Single-Center Experience

BACKGROUND

Although transarterial embolization (TAE) with Onyx has become popular for the treatment of dural arteriovenous fistulas (DAVFs), transvenous embolization (TVE), surgery, and radiosurgery have continued to have a role. The aim of the present study was to compare the treatment outcomes stratified by the different treatment modalities.

METHODS

The data from 92 patients with DAVFs treated from January 2009 to June 2018 were retrospectively reviewed. The treatment strategies were decided by a multidisciplinary team according to the patient's clinical status and angiographic findings. The clinical and radiologic data were analyzed and correlated with the treatment modality.

RESULTS

A total of 101 procedures were performed in the 92 patients. TAE, TVE, surgery, and radiosurgery were performed in 31, 49, 12, and 9 procedures, respectively. Complete and near complete occlusion was achieved in 13 cases treated with TAE (41.9%), 41 treated with TVE (83.7%), and 10 with surgery (83.3%), as shown on immediate postprocedural angiography (P < 0.001). Retreatment was needed in 9 patients in the TAE group and none in the TVE or surgery groups (P < 0.001). Surgery (n = 1), TVE (n = 3), TAE (n = 1), and radiosurgery (n = 4) were used for patients requiring retreatment. At the last follow-up examination (mean, 26.5 ± 23.9 months), 66 of 72 DAVFs (91.6%) showed angiographic complete occlusion. Clinically, the initial symptoms had disappeared or improved in 87 of 90 patients (96.7%) at the last follow-up evaluation (mean, 26.4 ± 26.8 months).

CONCLUSIONS

Even in the Onyx era, other treatment modalities still have important roles, as shown in the present study. Therefore, the selection of the appropriate treatment modality should be individualized by the angiographic findings and clinical symptoms.

Red Flags in the Assessment of Adult Ophthalmoplegia

Acquired ophthalmoplegia can represent a harbinger of vision and life-threatening disease. Recognition of select clinical "red flags" on history or examination can facilitate early diagnosis. This article reviews relevant clinical pearls for the detection of dire causes of acquired ophthalmoplegia in adults including myasthenia gravis, carotid cavernous fistula, giant cell arteritis, and thiamine deficiency. Prompt treatment of all of these disorders can either reverse or halt the progression of visual manifestations.

Carotid-cavernous fistula: current concepts in aetiology, investigation, and management

A carotid-cavernous fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus and may be classified as either direct or dural. Direct CCFs are characterized by a direct connection between the internal carotid artery (ICA) and the cavernous sinus, whereas dural CCFs result from an indirect connection involving cavernous arterial branches and the cavernous sinus. Direct CCFs frequently are traumatic in origin and also may be caused by rupture of an ICA aneurysm within the cavernous sinus, Ehlers-Danlos syndrome type IV, or iatrogenic intervention. Causes of dural CCFs include hypertension, fibromuscular dysplasia, Ehlers-Danlos type IV, and dissection of the ICA. Evaluation of a suspected CCF often involves non-invasive imaging techniques, including standard tonometry, pneumotonometry, ultrasound, computed tomographic scanning and angiography, and/or magnetic resonance imaging and angiography, but the gold standard for classification and diagnosis remains digital subtraction angiography. When a direct CCF is confirmed, first-line treatment is endovascular intervention, which may be accomplished using detachable balloons, coils, liquid embolic agents, or a combination of these tools. As dural CCFs often resolve spontaneously, low-risk cases may be managed conservatively. When invasive treatment is warranted, endovascular intervention or stereotactic radiosurgery may be performed. Modern endovascular techniques offer the ability to successfully treat CCFs with a low morbidity and virtually no mortality.

Bilateral Traumatic Caroticocavernous Fistulas: A Case Report and Review of the Literature

A traumatic caroticocavernous fistula (CCF) is an acquired, abnormal communication between the internal carotid artery and the cavernous sinus, secondary to trauma. This rare condition can initially be misdiagnosed, because its presentation shares features common to those of facial trauma, which can result in serious complications. We describe a case of bilateral CCF in an adult patient after a road traffic accident.

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.

Embolization of Dural Arteriovenous Fistula of the Cavernous Sinus Through Percutaneous Ultrasound-Guided Puncture of the Facial Vein

BACKGROUND

The goal of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus and consequently in the ophthalmic veins. The traditional approach in the treatment of these fistulae is transvenous endovascular occlusion of the cavernous sinus. Transvenous embolization has been proven to be safe and can provide complete and permanent occlusion of the fistula in a single session. The most commonly used venous pathway is the inferior petrosal sinus, but, if it is inaccessible, then, the superior ophthalmic vein is considered; nonetheless, it can require a surgical exposure. Other pathways include the transfemoral transfacial vein. An arterial approach is considered usually when venous approach pathways fail. Arterial occlusion of feeders supplying the fistula is associated with a greater risk of embolic complications.

CASE DESCRIPTION

We report a case of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein.

CONCLUSIONS

We propose an alternative pathway when the conventional transvenous approach through the inferior petrosal sinus is excluded. An ultrasound-guided facial vein approach can be considered as a direct and safe alternative to reach the cavernous sinus and obtain exclusion of the fistula.

Successful Coil Embolization of Pediatric Carotid Cavernous Fistula Due to Ruptured Posttraumatic Giant Internal Carotid Artery Aneurysm

BACKGROUND

The goal of the treatment of direct carotid cavernous fistula (CCF) is to occlude the arteriovenous shunt and to preserve the patency of the concerned internal carotid artery. However, for the ipsilateral posttraumatic fragile cerebrum, coil embolization plus parent artery occlusion for the high-flow direct CCF is better for the prevention of hyperperfusion syndrome and intracranial hemorrhage. We experienced such a case and managed it successfully.

CASE DESCRIPTION

A 6-year-old boy had severe head trauma caused by being hit by a car. He was transferred to our department and diagnosed as having left acute subdural hematoma and acute brain swelling. Emergent evacuation of hematoma and external decompression were performed. He was treated for severe brain swelling in the intensive care unit for 2 months. Cranioplasty was performed 3 months after the injury. His right hemiparesis and aphasia persisted, so he was transferred to a rehabilitation hospital. However, 2 years after the head injury, he was referred to our department because of abducens nerve palsy. He was diagnosed as having a symptomatic posttraumatic direct CCF, which was caused by a ruptured left cavernous giant internal carotid artery aneurysm. The direct CCF was treated with coil embolization of the giant aneurysm and parent artery occlusion.

CONCLUSIONS

Coil embolization of the aneurysm and parent artery occlusion for the posttraumatic direct CCF was a good option to manage the abducens nerve palsy and to prevent postoperative hyperperfusion.

Direct carotid cavernous sinus fistulae: vessel reconstruction using flow-diverting implants

Purpose

Retrospective evaluation of our experience with the use of flow diverters (FD) for the endovascular treatment of direct carotid-cavernous sinus fistulae (diCCF).

Methods

Between 2011 and 2015, 14 consecutive patients with 14 diCCF were treated with FD alone or in combination with other implants in a single institution.

Results

A total of 21 sessions were performed in 14 patients. FD placement was technically successful in all cases without an adverse event. Patients were treated with FD alone (n = 5), FD and covered stents (n = 2), FD and coils (n = 7). A total of 59 FD (24 Pipeline Embolization Device, Medtronic; 35 p64 Flow Modulation Device, phenox), 291 coils, and 3 stent grafts were used. Three of 14 diCCF were completely occluded after the 1^st session, a minor residual shunt was found in 7/14, and in the remaining 4/14 patients, the shunt volume was reduced significantly. The mean follow-up period encompassed 20 months. Additional treatment included transvenous coil occlusion (n = 3) and/or further FD deployment (n = 5). An asymptomatic internal carotid artery (ICA) occlusion was encountered in 2 patients, related to an interruption of antiaggregation. At the last follow-up, 10/14 patients were free from ocular symptoms (71 %), 2 had residual exophthalmos, and no patient had clinical deterioration.

Conclusion

The usage of FD for the treatment of diCCF is straightforward. Injury of the cranial nerves can be avoided. In most cases, ocular symptoms improve. Several FD layers and/or an adjunctive venous coil occlusion are required. Complete occlusion of a diCCF may take weeks or months and long-term antiaggregation is required. In the future, a flexible stent graft might be a better solution.

Traumatic posterior communicating artery-cavernous fistula, angioarchitecture, and possible pathogenesis: a case report and literature review

Carotid-cavernous fistulas (CCFs) are an abnormal vascular shunt between the carotid artery and the cavernous sinus, and were traditionally classified into four subtypes based on the detailed fistulas anatomy and arterial supply. CCFs are frequently encountered in patients with traumatic skull base fractures. In this report, we present one such case caused by two head traumas. Computed tomography and digital subtraction angiography confirmed that this CCF arose from posterior communicating artery of the internal carotid artery, which is not included in the traditional Barrow et al's categorization. The possible mechanisms include laceration of dural mater of posterior clinoid process and laceration or pseudoaneurysm formation of posterior communicating artery. This case was successfully treated with endovascular coil embolization.

Mid- and long-term outcomes of carotid-cavernous fistula endovascular management with Onyx and n-BCA: experience of a single tertiary center

INTRODUCTION

Endovascular therapy is the preferred treatment for most carotid-cavernous fistulas (CCFs). Early reports have documented excellent initial clinical and radiographic outcomes after embolization of CCFs with Onyx or n-butyl cyanoacrylate (n-BCA), but little evidence is available about the long-term durability of this technique.

OBJECTIVE

To characterize the long-term durability of CCF liquid embolization.

METHODS

The authors retrospectively reviewed a database of 24 CCFs in 21 consecutive patients who underwent Onyx or n-BCA embolization of a CCF from 2006 to 2013 at our institution.

RESULTS

A total of 25 Onyx or n-BCA embolization procedures were attempted and 24 successfully completed during the study, resulting in complete or near-complete occlusion by the end of the study in all 24 CCFs (obliteration success, 100%). Attempted embolization in a single CCF failed initially, but was performed successfully at a later date by a different approach. None of the 24 CCFs recanalized, regrew, or required any further treatment subsequent to Onyx or n-BCA embolization throughout a mean 12.4 months of angiographic follow-up (range 1-36 months). Clinically significant complications were seen in three embolization procedures, including cranial nerve palsies (n=1), embolic infarct (n=1), and intraperitoneal hemorrhage (n=1).

CONCLUSIONS

Early evidence has indicated that endovascular embolization with Onyx is relatively safe and effective at achieving an initial angiographic cure for CCFs. Results of our series suggest that angiographic and clinical outcomes of Onyx and n-BCA embolization remain stable at mid- and long-term follow-up.

Vascular lesions of the central skull base region

The arterial and venous structures of the central skull base region form complex anatomical relationships with each other and with adjacent osseous and neural structures. Vascular structures including the cavernous sinuses and internal carotid arteries can be displaced, encased, or invaded by neoplastic, inflammatory, or infectious lesions of the central skull base. Consequently, the vascular structures have a unique role in determining the imaging appearance, clinical significance, and therapeutic options of lesions occurring in the central skull base. This article briefly reviews the basic anatomy of the cavernous sinus and the relationship of the internal carotid artery to the cavernous sinus and central skull base. The major imaging features of some common vascular lesions, including skull base aneurysm, carotid-cavernous fistula, and cavernous sinus thrombosis are presented.

Ophthalmic vein compression for selected benign low-flow cavernous sinus dural arteriovenous fistulas

Dural arteriovenous fistulas (DAVFs) of the cavernous sinus are acquired arteriovenous shunts between the dural branches of the internal and external carotid arteries and the cavernous sinus. These fistulas may present with cortical venous reflux, but more commonly drain antegradely toward the superior ophthalmic vein (SOV). Transvenous embolization is the most common endovascular treatment, but in some cases transvenous access to the compartment of the shunt may not be possible. In cases with no corticovenous reflux, manual compression of the SOV is an excellent alternative treatment, which is well known but rarely reported in the literature. The authors describe a series of 3 cavernous DAVFs with anterior drainage treated successfully by intermittent manual compression of the SOV.

Endovascular treatment of cranial arteriovenous malformations and dural arteriovenous fistulas

Pial arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) are high-flow vascular lesions with abnormal communications between the arterial and venous system. AVMs are congenital lesions, whereas DAVFs are considered acquired lesions. Both can cause significant morbidity and mortality if they rupture and result in intracranial hemorrhage. The primary goal of treatment is to eliminate the risk of bleeding or at least decrease it. Because the epidemiology, clinical presentation, and classification of AVMs and DAVFs have been covered in previous articles in this issue, the authors only briefly touch on these subjects as they relate to endovascular treatment.