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Saleem MS, Yadlapalli SS, Jamil S, Mekowulu FC, Saad M, Sadiq A, Rashid U, Saleem F. Traumatic Carotid Cavernous Fistula Resulting in Symptoms in the Ipsilateral Eye: A Case Report. Cureus 2022; 14:e30950. [DOI: 10.7759/cureus.30950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
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2
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Cossu G, Atkins T, Hajdu SD, Puccinelli F, Daniel RT, Messerer M. Hemorrhagic direct traumatic carotid-cavernous fistula during endoscopic transsphenoidal surgery: intraoperative management and endovascular treatment. NEUROSURGICAL FOCUS: VIDEO 2020; 2:V1. [PMID: 36284789 PMCID: PMC9542588 DOI: 10.3171/2020.4.focusvid.19918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/07/2020] [Indexed: 02/02/2023]
Abstract
Carotid-cavernous fistula (CCF) is a rare complication after transsphenoidal surgery with only 10 cases published (Ahuja et al., 1992; Cinar et al., 2013; Cossu et al., 2020; Dolenc et al., 1999; Kalia et al., 2009; Karaman et al., 2009; Kocer et al., 2002; Koitschev et al., 2006; Pigott et al., 1989; Takahashi et al., 1969). Intraoperative findings vary from unrecognized events to life-threatening hemorrhages. We provide a description of the management of an acute CCF occurring during sphenoidotomy in a patient with pituitary apoplexy. Osteotomy performed in the rostrum resulted in a fracture, which extended toward the intracavernous carotid artery. Bleeding was managed with mechanical compression. Endovascular treatment allowed closure of the fistula through transarterial coiling and glue. Arterial patency was preserved and the patient had no new neurological deficit. Drilling should be considered over osteotomy for the anterior sphenoidotomy. The video can be found here: https://youtu.be/0Me23xIVeNI.
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Affiliation(s)
| | | | - Steven D. Hajdu
- Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Francesco Puccinelli
- Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
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Holland LJ, Mitchell Ranzcr K, Harrison JD, Brauchli D, Wong Y, Sullivan TJ. Endovascular treatment of carotid-cavernous sinus fistulas: ophthalmic and visual outcomes. Orbit 2018; 38:290-299. [PMID: 30465621 DOI: 10.1080/01676830.2018.1544261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Lee J Holland
- a Department of Ophthalmology, Royal Brisbane and Women's Hospital , Herston , Queensland , Australia
| | - Ken Mitchell Ranzcr
- b Department of Medical Imaging, Royal Brisbane and Women's Hospital , Queensland , Australia
| | - John D Harrison
- a Department of Ophthalmology, Royal Brisbane and Women's Hospital , Herston , Queensland , Australia
| | - Damien Brauchli
- b Department of Medical Imaging, Royal Brisbane and Women's Hospital , Queensland , Australia
| | - Yun Wong
- c Department of Ophthalmology, James Cook University Hospital , Middlesbrough , UK
| | - Timothy J Sullivan
- a Department of Ophthalmology, Royal Brisbane and Women's Hospital , Herston , Queensland , Australia.,d Department of Ophthalmology, University of Queensland , St Lucia , Queensland , Australia
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4
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Wajima D, Nakagawa I, Park HS, Yokoyama S, Wada T, Kichikawa K, Nakase H. Successful Coil Embolization of Pediatric Carotid Cavernous Fistula Due to Ruptured Posttraumatic Giant Internal Carotid Artery Aneurysm. World Neurosurg 2016; 98:871.e23-871.e28. [PMID: 27923754 DOI: 10.1016/j.wneu.2016.11.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/25/2016] [Accepted: 11/26/2016] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Daisuke Wajima
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan.
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Hun Soo Park
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Shohei Yokoyama
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Takeshi Wada
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
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Abdulrauf SI, Ashour AM, Marvin E, Coppens J, Kang B, Hsieh TYY, Nery B, Penanes JR, Alsahlawi AK, Moore S, Abou Al-Shaar H, Kemp J, Chawla K, Sujijantarat N, Najeeb A, Parkar N, Shetty V, Vafaie T, Antisdel J, Mikulec TA, Edgell R, Lebovitz J, Pierson M, Pires de Aguiar PH, Buchanan P, Di Cosola A, Stevens G. Proposed clinical internal carotid artery classification system. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2016; 7:161-70. [PMID: 27630478 PMCID: PMC4994148 DOI: 10.4103/0974-8237.188412] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system. MATERIALS AND METHODS We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment. RESULTS The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%]; P < 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%]; P < 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%]; P < 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%; P < 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%]; P < 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring. CONCLUSIONS The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures.
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Affiliation(s)
- Saleem I Abdulrauf
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Ahmed M Ashour
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Eric Marvin
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jeroen Coppens
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Brian Kang
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tze Yu Yeh Hsieh
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Breno Nery
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Juan R Penanes
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Aysha K Alsahlawi
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Shawn Moore
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Hussam Abou Al-Shaar
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Joanna Kemp
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Kanika Chawla
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Nanthiya Sujijantarat
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Alaa Najeeb
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Nadeem Parkar
- Department of Radiology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Vilaas Shetty
- Department of Radiology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tina Vafaie
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jastin Antisdel
- Department of Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tony A Mikulec
- Department of Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Randall Edgell
- Department of Neurology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jonathan Lebovitz
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Matt Pierson
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | | | - Paula Buchanan
- Center for Outcomes Research, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Angela Di Cosola
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - George Stevens
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
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Wendl CM, Henkes H, Martinez Moreno R, Ganslandt O, Bäzner H, Aguilar Pérez M. Direct carotid cavernous sinus fistulae: vessel reconstruction using flow-diverting implants. Clin Neuroradiol 2016; 27:493-501. [PMID: 27129454 PMCID: PMC5719129 DOI: 10.1007/s00062-016-0511-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 03/02/2016] [Indexed: 11/24/2022]
Abstract
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 1st 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.
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Affiliation(s)
- C M Wendl
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany. .,Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Universitätsklinikum Regensburg, Regensburg, Germany.
| | - H Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.,Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
| | - R Martinez Moreno
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - H Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
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7
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Ono K, Oishi H, Tanoue S, Hasegawa H, Yoshida K, Yamamoto M, Arai H. Direct carotid-cavernous fistulas occurring during neurointerventional procedures. Interv Neuroradiol 2015; 22:91-6. [PMID: 26628454 DOI: 10.1177/1591019915617321] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 10/03/2015] [Indexed: 11/15/2022] Open
Abstract
This study shows the frequency and types of carotid-cavernous fistula (CCF) complications that occurred during endovascular treatment. Transarterial endovascular surgeries involving the anterior circulation were performed for 1071 cases at our hospitals during four years. CCFs occurred in nine of 1071 cases (0.8%). CCF risk factors were female sex (p=0.032), aneurysmal location in the paraclinoid portion (p<0.001), and use of a distal access catheter (DAC) (p<0.001). There were no significant correlations between CCF risk and procedure type (p=0.411-1.0) and balloon use or nonuse (p=0.492). Eighty-nine percent (eight of nine) of the CCFs occurred at the genu of a cavernous internal carotid artery (ICA). Two cases of CCF disappeared spontaneously. The shunt was decreased by balloon expansion in one case, no additional treatment was required in one case, and five cases required transarterial fistula coil embolization. It is necessary to remember that a CCF may occur especially in aneurysmal treatment using a DAC in a female patient. The DAC and the 0.035-inch guidewire should be kept proximal to the carotid siphon and not go beyond it. When we cannot avoid navigating beyond it, we should consider using a softer DAC. In the case of a CCF caused by a DAC, it may be cured spontaneously or is treatable by transarterial coil embolization.
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Affiliation(s)
- Kenichiro Ono
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Shunsuke Tanoue
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Hiroshi Hasegawa
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Kensaku Yoshida
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Munetaka Yamamoto
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
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Iancu D, Lum C, Ahmed ME, Glikstein R, Dos Santos MP, Lesiuk H, Labib M, Kassam AB. Flow diversion in the treatment of carotid injury and carotid-cavernous fistula after transsphenoidal surgery. Interv Neuroradiol 2015; 21:346-50. [PMID: 26015526 DOI: 10.1177/1591019915582367] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We describe a case of iatrogenic carotid injury with secondary carotid-cavernous fistula (CCF) treated with a silk flow diverter stent placed within the injured internal carotid artery and coils placed within the cavernous sinus. Flow diverters may offer a simple and potentially safe vessel-sparing option in this rare complication of transsphenoidal surgery. The management options are discussed and the relevant literature is reviewed.
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Affiliation(s)
- Daniela Iancu
- Department of Medical Imaging, Section of Neuroradiology, University of Ottawa, The Ottawa Hospital, Canada
| | - Cheemum Lum
- Department of Medical Imaging, Section of Neuroradiology, University of Ottawa, The Ottawa Hospital, Canada
| | - Muhammad E Ahmed
- Department of Medical Imaging, Section of Neuroradiology, University of Ottawa, The Ottawa Hospital, Canada
| | - Rafael Glikstein
- Department of Medical Imaging, Section of Neuroradiology, University of Ottawa, The Ottawa Hospital, Canada
| | - Marlise P Dos Santos
- Department of Medical Imaging, Section of Neuroradiology, University of Ottawa, The Ottawa Hospital, Canada
| | - Howard Lesiuk
- Department of Surgery, Section of Neurosurgery, University of Ottawa, The Ottawa Hospital, Canada
| | - Mohamed Labib
- Department of Surgery, Section of Neurosurgery, University of Ottawa, The Ottawa Hospital, Canada
| | - Amin B Kassam
- Department of Surgery, Section of Neurosurgery, University of Ottawa, The Ottawa Hospital, Canada
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9
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Labib MA, Prevedello DM, Carrau R, Kerr EE, Naudy C, Abou Al-Shaar H, Corsten M, Kassam A. A Road Map to the Internal Carotid Artery in Expanded Endoscopic Endonasal Approaches to the Ventral Cranial Base. Oper Neurosurg (Hagerstown) 2014; 10 Suppl 3:448-71; discussion 471. [DOI: 10.1227/neu.0000000000000362] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Injuring the internal carotid artery (ICA) is a feared complication of endoscopic endonasal approaches.
OBJECTIVE:
To introduce a comprehensive ICA classification scheme pertinent to safe endoscopic endonasal cranial base surgery.
METHODS:
Anatomic dissections were performed in 33 cadaveric specimens (bilateral). Anatomic correlations were analyzed.
RESULTS:
Based on anatomic correlations, the ICA may be described as 6 distinct segments: (1) parapharyngeal (common carotid bifurcation to ICA foramen); (2) petrous (carotid canal to posterolateral aspect of foramen lacerum); (3) paraclival (posterolateral foramen lacerum to the superomedial aspect of the petrous apex); (4) parasellar (superomedial petrous apex to the proximal dural ring); (5) paraclinoid (from the proximal to the distal dural rings); and (6) intradural (distal ring to ICA bifurcation). Corresponding surgical landmarks included the Eustachian tube, the fossa of Rosenmüller, and levator veli palatini for the parapharyngeal segment; the vidian canal and V3 for the petrous segment; the fibrocartilage of foramen lacerum, foramen rotundum, maxillary strut, lingular process of the sphenoid bone, and paraclival protuberance for the paraclival segment; the sellar floor and petrous apex for the parasellar segment; and the medial and lateral opticocarotid and lateral tubercular recesses, as well as the distal osseous arch of the carotid sulcus for the paraclinoid segment.
CONCLUSION:
The proposed endoscopic classification outlines key anatomic reference points independent of the vessel's geometry or the sinonasal pneumatization, thus serving as (1) a practical guide to navigate the ventral cranial base while avoiding injury to the ICA and (2) further foundation for a modular access system.
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Affiliation(s)
- Mohamed A. Labib
- Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Ricardo Carrau
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University, Columbus, Ohio
| | | | | | - Hussam Abou Al-Shaar
- Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Martin Corsten
- Department of Otolaryngology, University of Ottawa, Ottawa, Ontario, Canada
| | - Amin Kassam
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
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10
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Abstract
Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.
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Affiliation(s)
- Jason A Ellis
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA.
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11
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Berker M, Aghayev K, Saatci I, Palaoğlu S, Onerci M. Overview of vascular complications of pituitary surgery with special emphasis on unexpected abnormality. Pituitary 2010; 13:160-7. [PMID: 19728100 DOI: 10.1007/s11102-009-0198-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Arterial bleeding during transsphenoidal surgery for pituitary adenoma is known complication. This usually happens due to rupture of intracavernous carotid or delayed hemorrhage due to the carotico-cavernous fistula and/or pseudoaneurysm. There is also evidence that cavernous carotid aneurysms may occur with pituitary tumors, yet largest series failed to demonstrate any link between aneurysm formation and pituitary tumors. Usually such an aneurysm rupture results in formation of carotico-cavernous fistula. However, pituitary apoplexy and even epistaxis have been reported. In this paper we present a patient with recurrent pituitary adenoma and cavernous carotid artery aneurysm, which caused significant hemorrhage during the surgery. Although retrospective analysis of MRI disclosed that the patient had the aneurysm before the first surgery, it remained silent until the second operation. Therefore neurosurgeons should be very susceptive to any signal changes on preoperative MR images, especially in recurrent cases, where normal anatomical relations are disturbed by fibrotic tissue. Also, we reviewed the vascular complication of pituitary surgery based on the literature.
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Affiliation(s)
- Mustafa Berker
- Department of Neurosurgery, Hacettepe School of Medicine, Ankara, Turkey.
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12
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Liu GT, Volpe NJ, Galetta SL. Eye movement disorders. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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13
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Barzaghi LR, Losa M, Giovanelli M, Mortini P. Complications of transsphenoidal surgery in patients with pituitary adenoma: experience at a single centre. Acta Neurochir (Wien) 2007; 149:877-85; discussion 885-6. [PMID: 17616842 DOI: 10.1007/s00701-007-1244-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 04/04/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This paper reports the complications of transsphenoidal surgery for pituitary adenomas in a series of 1240 consecutive patients operated at our Institute between 1990 and 2004 (first operations) and indicate the clinical characteristics of patients which affected surgical morbidity and mortality. METHODS According to tumour type, there were 420 (33.9%) non-functioning pituitary adenomas (NFPA), 349 (28.1%) GH-secreting, 288 (23.2%) ACTH-secreting, 155 (12.5%) prolactin (PRL)-secreting, and 28 (2.3%) TSH-secreting adenomas. The mean age of patients was 43.7 +/- 0.4 yr and 122 patients (9.9%) were 65 yr or older; the female/male ratio was 1.5/1. There were 370 (29.8%) microadenomas and 870 (70.2%) macroadenomas of which 54 (4.4%) were giant adenomas. RESULTS The series mortality was 0.2%, the medical morbidity 1.9%, and the surgical morbidity 3.5%. Medical complications were significantly more frequent in patients older than 65 yr (4.9 vs. 1.4%; p = 0.009) and in patients with giant adenomas (5.6 vs. 1.6%; p = 0.03). Multivariate analysis showed that both variables were independently associated with a higher morbidity rate. The surgical morbidity was increased in giant adenomas (15 vs. 3%; p = 0.0001), in NFPA (6.2 vs. 2.1% in secreting adenomas; p = 0.0002) and in patients older than 65 yr (6.6 vs. 3.1%; p = 0.05). Multivariate analysis showed that only giant size was independently associated with an increased surgical morbidity rate. CONCLUSIONS In our experience, the size of the adenoma was a risk factor for medical and surgery related complications and age over 65 yr for medical complications alone.
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Affiliation(s)
- L R Barzaghi
- Pituitary Unit, Department of Neurosurgery, Istituto Scientifico San Raffaele, Università Vita-Salute, Milan, Italy.
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Feiner L, Bennett J, Volpe NJ. Cavernous sinus fistulas: carotid cavernous fistulas and dural arteriovenous malformations. Curr Neurol Neurosci Rep 2003; 3:415-20. [PMID: 12914685 DOI: 10.1007/s11910-003-0025-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Direct and indirect carotid cavernous sinus fistulas are uncommon vascular anomalies that result in increased pressure in the cavernous sinus. The subsequent changes in blood flow lead to orbital venous congestion, cranial neuropathies, and glaucoma. The following review summarizes knowledge of the clinical features, natural history, diagnostic testing, and therapy for carotid cavernous sinus fistulas.
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Affiliation(s)
- Leonard Feiner
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania, 51 North 39th Street, Philadelphia, PA 19104, USA.
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Abstract
Traumatic vascular injury to the intracranial and extracranial circulation can be sequelae of blunt, penetrating, or iatrogenic insults to the head, face, or neck. Treatment options include conservative medical management, or more invasive surgical or endovascular therapy. The appropriate treatment depends on the risk-benefit ratio of each option considering the natural history of each. Injuries include mild intimal irregularities, intimal flaps, pseudoaneurysms, fistulas, and occlusions. Need for treatment is partly determined by the collateral circulation to the brain, and the degree to which the lesion is thrombogenic. Advances in endovascular devices and techniques provide us with less invasive alternatives to surgery intervention or allow the interventionalist to treat lesions not treatable by any other modality.
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Affiliation(s)
- Donald W Larsen
- Department of Neurological Surgery and Radiology, Keck School of Medicine, University of Southern California, Department of Interventional Neuroradiology, University of Southern California Medical Center, Los Angeles, CA, USA.
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Abstract
Vascular complication of transsphenoidal surgery can lead to mortality and serious morbidity. In a series of 3,061 transsphenoidal operations for pituitary disease, 24 such complications were encountered, seven of which were fatal. The anatomic substrate for such complications is discussed, along with technical aspects of surgery and other methods for the avoidance of vascular complications.
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Affiliation(s)
- E R Laws
- Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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Fukushima T, Maroon JC. Repair of carotid artery perforations during transsphenoidal surgery. SURGICAL NEUROLOGY 1998; 50:174-7. [PMID: 9701124 DOI: 10.1016/s0090-3019(96)00416-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hemorrhage from carotid artery injury during transsphenoidal surgery is an unusual, but potentially fatal complication. METHODS Among six patients experiencing laceration or perforation of the carotid artery, we treated four with a new technique using Teflon mesh and methyl methacrylate to form an external, artificial wall over the laceration and the carotid artery. RESULTS In all four cases, hemorrhage was successfully controlled without neurologic deficit to the patient or complications frequently associated with the standard technique of nasal and sphenoid sinus packing removal. CONCLUSIONS Our new technique may be superior to packing alone, as well as potentially life-saving to the patient.
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Affiliation(s)
- T Fukushima
- ANI Department of Neurosurgery, Allegheny General Hospital and The Medical College of Pennsylvania and Hahnemann University, Pittsburgh, USA
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Scientific Posters. Interv Neuroradiol 1997. [DOI: 10.1177/15910199970030s114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997; 40:225-36; discussion 236-7. [PMID: 9007854 DOI: 10.1097/00006123-199702000-00001] [Citation(s) in RCA: 678] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE The primary objectives of this report were, first, to determine the number and incidence of complications of transsphenoidal surgery performed by a cross-section of neurosurgeons in the United States and, second, to ascertain the influence of the surgeon's experience with the procedure on the occurrence of these complications. The secondary objective was to review complications of transsphenoidal surgery from the standpoint of their causation, treatment, and prevention. METHODS Questionnaires regarding 14 specific complications of transsphenoidal surgery were mailed to 3172 neurosurgeons. The data reported were analyzed from the 958 respondents (82%) who reported performing the operation. The neurosurgeons surveyed were asked to estimate the number of transsphenoidal operations performed, to identify any complications observed, and to estimate the percentage of operations that had resulted in any of the 14 specific complications. The 958 respondents were placed into three experience groups, based on the number of transsphenoidal operations performed. The data were analyzed by using chi 2 tests and Spearman correlation coefficients. The secondary objectives were met through a detailed review of the literature, in light of our experience. RESULTS Of the respondents, 87.3% reported having performed < 200 operations and 9.7% reported 200 to 500 previous operations. The remaining 3% reported more than 500 previous operations. More extensive previous experience with transsphenoidal surgery was associated with a greater likelihood of having witnessed each specific complication. The mean operative mortality rate for all three groups was 0.9%. Anterior pituitary insufficiency (19.4%) and diabetes insipidus (17.8%) were complications with the highest incidence of occurrence. The overall incidence of cerebrospinal fluid fistulas was 3.9%. Other significant complications, such as carotid artery injuries, hypothalamic injuries, loss of vision, and meningitis, occurred with incidence rates between 1 and 2%. An inverse relationship was found between the experience group and the likelihood of complications, as indicated by significant negative Spearman correlation coefficients for all but 2 of the 14 complications listed in the survey (P < 0.05). Thus, increased experience with transsphenoidal surgery seems to be associated with a decreased percentage of operations resulting in complications. Some caution should be exercised in interpreting these data, because they are based on the respondents' estimates. CONCLUSION Transsphenoidal surgery seems to be a reasonably safe procedure, with a mortality rate of less than 1%. However, a significant number of complications do occur. The incidence of these complications seems to be higher, with statistical significance, in the hands of less experienced surgeons. The learning curve seems to be relatively shallow, because a statistically significantly decreased incidence of morbidity and death could be documented after 200 and even 500 transsphenoidal operations. Better understanding of the indications for transsphenoidal surgery and improved familiarity with the regional anatomy should further lower the incidence of death and morbidity resulting from this procedure in the hands of all neurosurgeons.
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Affiliation(s)
- I Ciric
- Division of Neurosurgery, Evanston Hospital, Northwestern University Medical School, Illinois, USA
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Ahuja A, Guterman LR, Hopkins LN. Carotid cavernous fistula and false aneurysm of the cavernous carotid artery: complications of transsphenoidal surgery. Neurosurgery 1992; 31:774-8; discussion 778-9. [PMID: 1407467 DOI: 10.1227/00006123-199210000-00025] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Injury to the cavernous internal carotid artery is an unusual and serious complication of transsphenoidal surgery. Two such patients with injury to the carotid artery, referred for endovascular treatment, are reported. The clinical course and successful treatment of these patients, one with an intracavernous false aneurysm and one with a carotid cavernous fistula, are described. A review of these vascular complications of transsphenoidal surgery is presented.
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Affiliation(s)
- A Ahuja
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, State University of New York, Buffalo
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Pigott TJ, Holland IM, Punt JA. Carotico-cavernous fistula after trans-sphenoidal hypophysectomy. Br J Neurosurg 1989; 3:613-6. [PMID: 2818855 DOI: 10.3109/02688698909002855] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A case is presented of a 48-year-old woman with an iatrogenic carotico-cavernous fistula consequent upon a transphenoidal hypophysectomy. Successful closure of the fistula was achieved by interventional radiology. The causes and management of vascular injuries during trans-sphenoidal pituitary surgery are reviewed and discussed.
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Affiliation(s)
- T J Pigott
- Department of Neuroradiology & Neurosurgery, University Hospital, Nottingham, United Kingdom
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