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

Delayed Iatrogenic Direct Carotid Cavernous Fistula Following Flow Diversion for Aneurysm With Spontaneous Healing: A Case Report

An abnormal connection between the carotid artery and cavernous sinus is referred to as a carotid cavernous fistula (CCF). A direct CCF results when the connection occurs between the intracranial internal carotid artery (ICA) and the cavernous sinus. These events are typically the result of a head injury, but can also be iatrogenic, resulting from various intracranial procedures. Direct CCF occurrences rarely heal spontaneously due to the high flow rate across the fistula. In this report, we present an uncommon case involving a delayed iatrogenic direct CCF, which developed following the placement of a pipeline flow-diverting stent that was used to treat a cerebral aneurysm. Interestingly, this unusual iatrogenic direct CCF subsequently spontaneously resolved within a few months. To our knowledge, this is the only case of a delayed CCF occurring with the use of a flow-diverting sent, which then resolved on its own. This report recounts our experience with the case.

Carotid-cavernous fistula following mechanical thrombectomy of the tortuous internal carotid artery: A case report

BACKGROUND

A carotid-cavernous fistula (CCF) is an abnormal connection between the internal carotid artery (ICA) and the cavernous sinus. Although direct CCFs typically result from trauma or as an iatrogenic complication of neuroendovascular procedures, they can occur as surgery-related complications after mechanical thrombectomy (MT). With the widespread use of MT in patients with acute ischemic stroke complicated with large vessel occlusion, it is important to document CCF following MT and how to avoid them. In this study, we present a case of a patient who developed a CCF following MT and describe in detail the characteristics of ICA tortuosity in this case.

CASE SUMMARY

A 60-year-old woman experienced weakness in the left upper and lower limbs as well as difficulty speaking for 4 h. The neurological examination revealed left central facial paralysis and left hemiplegia, with a National Institutes of Health Stroke Scale score of 9. Head magnetic resonance imaging revealed an acute cerebral infarction in the right basal ganglia and radial crown. Magnetic resonance angiography demonstrated an occlusion of the right ICA and middle cerebral artery. Digital subtraction angiography demonstrated distal occlusion of the cervical segment of the right ICA. We performed suction combined with stent thrombectomy. Then, postoperative angiography was performed, which showed a right CCF. One month later, CCF embolization was performed, and the patient's clinical symptoms have significantly improved 5 mo after the operation.

CONCLUSION

Although a CCF is a rare complication after MT, it should be considered. Understanding the tortuosity of the internal carotid-cavernous sinus may help predict the complexity of MT and avoid this complication.

Carotid-cavernous sinus fistula following mechanical thrombectomy in acute ischaemic stroke: a rare complication

Carotid-cavernous sinus fistulas (CCFs) are abnormal communications between the internal carotid artery (ICA) and the cavernous sinus (CS). Direct CCFs are associated with trauma or are iatrogenic complications of neuroendovascular procedures. Meanwhile, mechanical endovascular thrombectomy (MT) in acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO) has been established as a common treatment approach. However, MT is not without its risks of complications, and only a few reports exist on CCF occurring after MT. Here, we present a case of a 63-year-old patient with iatrogenic high-flow CCF of the right horizontal cavernous ICA segment (C4) following repeated MT due to LVO of the middle cerebral artery, and the recent literature is reviewed.