Transarterial Treatment of Traumatic Carotid Cavernous Sinus Fistula with Carotid Artery Dissection and Ruptured Pseudoaneurysm Using Flow Diverter and Detachable Coils

Treatment of carotid cavernous sinus fistulas with flow diverters. A case report and systematic review

INTRODUCTION

Carotid cavernous fistulas (CCFs) are rare, usually follow head trauma or aneurysmal rupture. Recent treatment options include endovascular techniques such as flow diversion devices (FDDs).

OBJECTIVE

To present our case treated with FDD application with transarterial cavernous-sinus coiling and present a systematic review on the use and effectiveness of FDDs in CCF treatment.

MATERIALS AND METHODS

We present our case of CCF treatment with FDD. A search was also conducted in PubMed, EMBASE and Cochrane until November 2020. Reference lists were also cross-checked.

RESULTS

Including our case, thirty-eight patients were identified with a CCF that was treated with FDDs in sixteen studies. Twenty-two patients were females, nine were males and the rest unidentified. The mean age was 52,6 years (range 17-86, SD± 19.28). Thirty-six patients suffered from direct and two from indirect CCFs. Single FDD was used in four cases, single FDD with embolic materials in eleven cases, multiple overlapping FDDs were used in six cases and multiple overlapping FDDs with embolic materials were used in seventeen cases. Thirty-five patients (92,1%) had clinical improvement, immediate angiographic occlusion was seen in 44,7% of the cases, while long-term occlusion rate was 100% but with variable follow-up periods. One patient (2,6%) presented with a neurological deficit related to FDD deployment.

CONCLUSION

Targeted treatment of CCFs with single or overlapping FDDs with or without adjunct embolic agents offers a high success rate, both clinically and long-term angiographically compared to other endovascular methods alone. However, further research with multi-center prospective trials is warranted.

Balloon-Assisted Roadmap Technique to Enable Flow Diversion of a High-Flow Direct Carotid-Cavernous Fistula

BACKGROUND

The use of flow diverters as a first-line treatment for direct carotid cavernous fistula (CCF) is a relatively new approach in the neurointerventional field which allows obliteration of the fistula with less mass effect from coils in the cavernous sinus. Safe and successful deployment of a flow diverter requires adequate imaging of the parent vessel, which may be challenging in the setting of high-flow CCF without antegrade flow.

OBJECTIVE

To facilitate adequate parent vessel imaging in the setting of high-flow CCF to enable the safe development of a flow diverter device.

METHODS

Here we present the case of a patient with delayed presentation of post-traumatic direct CCF after a motor vehicle accident, with no antegrade flow past the fistulous connection. We used temporary balloon occlusion of the fistulous connection to enable road-map imaging of the parent vessel and flow-diverter placement. "Drag and drop" device opening in the middle cerebral artery facilitated better deployment of the flow-diverter against retrograde cavernous flow through the fistula.

RESULTS

Temporary balloon occlusion of the fistulous connection was used to acquire a roadmap to facilitate safe deployment of a flow diverter and subsequent treatment of the CCF with transvenous coil embolization, with complete resolution of symptoms.

CONCLUSION

Balloon-assisted roadmap use is a novel means of visualizing the parent vessel in direct CCF to facilitate safe flow diverter deployment.

Treatment of post-traumatic direct carotid-cavernous fistulas using flow diverting stents: Is it alone satisfactory?

BACKGROUND

Direct carotid cavernous fistula (CCF) occurs between the internal carotid artery (ICA) and the cavernous sinus. Carotid cavernous fistulas (CCFs) frequently present with chemosis, pulsatile proptosis, ocular bruit, vision loss, and occasionally intracerebral hemorrhage or seizure. In this article, we share our experience in endovascular treatment of six patients having this pathology with intracranial flow diverting stents with review of literatures.

CASE DESCRIPTION

All six patients had posttraumatic direct CCF, most of their signs and symptoms were visual disturbance, chemosis, orbital bruit, headache, paralysis of extraocular muscles. They were treated with flow diversion stents with or without coils or liquid embolizing material; transvenous and transarterial routes were used. Most of them underwent multiple sessions, and their conditions were improved dramatically.

CONCLUSION

The best and most effective method is to start the procedure by coiling to convert the high-flow fistula to an aneurysmal pouch with the smallest possible size in the cavernous sinus, and then close the defect site with one or two flow diversion devices (FDDs).

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.

Treatment of direct carotid-cavernous fistulas with flow diversion - does it work?

Direct carotid-cavernous fistulas (CCFs) are high flow lesions that can be challenging to treat. A number of recent reports suggest that flow diversion may be a viable treatment option. We present a case of a post-traumatic CCF successfully treated with flow diversion and provide a review of the literature. Our results suggest that flow diversion is a potentially effective treatment option for CCFs and is most successful when used as an adjunctive therapy.