Bilateral traumatic carotid-cavernous fistulas successfully treated by detachable balloon technique

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.

Bilateral carotid cavernous sinus fistula: a case report and review of the literature

Carotid cavernous fistula (CCF) is an abnormal vascular shunt from the carotid artery to the cavernous sinus. They are commonly classified based on hemodynamics, etiology or anatomically. Hemodynamic classification refers to whether the fistula is high or low flow. Etiology is commonly secondary to trauma or can occur spontaneously in the setting of aneurysm or medical conditions predisposing to arterial wall defects. Bilateral carotid cavernous fistulas are rare. We present a case of bilateral CCF secondary to trauma. Ophthalmology was urgently consulted to assess the patient in the intensive care unit (ICU) for red eye. The patient was found to have decreased vision, increased intraocular pressure, an afferent pupillary defect, proptosis, chemosis, and ophthalmoplegia. Subsequent neuro-imaging confirmed a bilateral CCF. The patient underwent two endovascular embolization procedures. Trauma is the most common cause of CCF and accounts for up to 75% of cases. Most common signs of CCF depend on whether it is high or low flow. High-flow CCF may present with chemosis, proptosis, cranial nerve palsy, increased intraocular pressure, diplopia, and decreased vision. Cerebral angiography is the gold standard diagnostic modality. First-line treatment consists of endovascular embolization with either a metallic coil, endovascular balloon or embolic agent. It is unclear in the literature if bilateral cases are more difficult to treat or have a different prognosis. Our patient required two endovascular procedures suggesting that endovascular intervention may have reduced efficacy in bilateral cases.

Cerebral hemorrhage after endovascular treatment of bilateral traumatic carotid cavernous fistulae with covered stents

Bilateral traumatic carotid-cavernous fistulae (TCCFs) is rarely encountered neurovascular disease. For treatment of TCCF, detachable balloons have been widely used. Nowadays, transarterial and/or transvenous coil embolization with placement of covered stents is adopted as another treatment method. We experienced a patient with a bilateral TCCFs who was successfully treated with covered stents. However, cerebral hemorrhage occurred in the bed of previous infarction one day after treatment. Hyperperfusion syndrome was considered as a possible cause of the hemorrhage, so that barbiturate coma therapy was started and progression of hemorrhage was stopped. We emphasize that cerebral hyperperfusion hemorrhage can occur even after successful endovascular treatment of TCCF.

Bilateral traumatic carotid cavernous fistula: the manifestations, transvascular embolization and prevention of the vascular complications after therapeutic embolization

Bilateral traumatic carotid cavernous fistula is very rare after traumatic brain and facial injury. We present a 68-year-old woman with bilateral traumatic carotid cavernous fistula, who was treated with transarterial embolization by detachable balloon on both fistulas and recovered completely. We also reviewed the presentations, treatment and the complications after the transarterial embolization of this disorder.

Bilateral traumatic carotid-cavernous fistulae: Strategies for endovascular treatment

BACKGROUND

Most traumatic carotid-cavernous fistula/e (TCCF) are unilateral, and simultaneous bilateral TCCF are uncommon. The purpose of this study was to evaluate the angiographic architecture of bilateral TCCF and report our experience with their endovascular management.

METHOD

Over 15 years, 252 consecutive patients with TCCF were referred to our institute for endovascular treatment. Bilateral TCCF occurred in 5 men and 2 women with a mean age of 31 years. The angiographic architectures of bilateral TCCF were evaluated with cerebral angiography. All patients underwent a single session of transarterial embolisation by using various permanent embolic materials and were followed up clinically or with angiography for a mean of 22 months (range 9-36 months).

FINDINGS

All patients presented with neuro-ophthalmic symptoms and signs. No new instances of cerebrovascular ischemia or intracranial haematoma resulted from bilateral TCCF. All fistulae were associated with partial arterial steal and were successfully occluded by using a detachable balloon and/or a detachable coil with or without a liquid adhesive. Of 14 TCCF, 9 were completely obliterated with preserved flow of the internal carotid artery (ICA). In the other 5 fistulae, the ICA had to be sacrificed to achieve occlusion because the anatomy of the fistula was complex. All fistula related symptoms resolved immediately or gradually during clinical follow up. No clinically significant procedure related neurological complications or recurrent fistulae were observed.

CONCLUSIONS

All bilateral TCCF were associated with a partial arterial steal phenomenon. Single session endovascular treatment using various embolic materials was effective in managing these high-flow fistulae. In all patients, it was possible to preserve one or both ICAs.