J Korean Neurotraumatol Soc.  2008 Dec;4(2):77-83. 10.13004/jknts.2008.4.2.77.

Endovascular Treatment for Type A Carotid Cavernous Fistulas with Detachable Coils

• Cho PG
• Whang K
• Pyen JS
• Hu C
• Hong SK
• Jung HH

• KMID: 2156154
• DOI: http://doi.org/10.13004/jknts.2008.4.2.77

Abstract

OBJECTIVE
Carotid cavernous fistulae (CCF) after head traumas are abnormal communications between the internal carotid artery and venous compartments of the cavernous sinus. Fistulae are uncommon but well-documented sequelae of craniofacial trauma. We report our experiences in placing detachable coils in the management of rare cases of direct CCF after head injuries.
METHODS
From January 2002 to December 2007, nine patients were admitted and treated for traumatic direct CCF at our hospital. The medical records and neuroimaging studies were retrospectively reviewed.
RESULTS
All 9 patients had previous head trauma histories and ocular symptoms including exophthalmos, conjunctiva injection, and chemosis. Angiography was performed to confirm the CCF and for treatment planning. According to the angiograph, three patients had pseudo-aneurysms. All of the patients were treated with detachable coils via the trans-arterial endovascular maneuver. Among them, two patients had recurrences, the first at postoperative day one and the other eleven days after the surgery. Both recurrences were retreated endovascularly. All nine patients were successfully treated anigographically by means of trans-arterial embolization and improved symptomatically within a week.
CONCLUSION
The etiology of CCF, especially type A, is well known. Also, the advances in interventional neuroradiology and cranial base surgery are chiefly responsible for the evolution of treatment strategies for CCF. Although other techniques and approaches with other materials may be useful, embolization with detachable coiling, as used in our cases, can be a safe and effective method to occlude the fistula and to improve symptoms.

Keyword

Carotid cavernous fistula; Coil; Endovascular treatment; Head trauma

MeSH Terms

Angiography
Carotid Artery, Internal
Cavernous Sinus
Caves
Conjunctiva
Craniocerebral Trauma
Exophthalmos
Fistula
Head
Humans
Medical Records
Neuroimaging
Recurrence
Retrospective Studies
Skull Base

Figure

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  FIGURE 1 Pre- and post-operative arterial phase of the ICA angiogram in the case 2 patient. A and B: AP and lateral view of the pre-operative angiogram. Left ophthalmic vein, middle cerebral vein, inferior petrosal sinus, and pterygoid plexus are prominent in the arterial phase suggesting a high-flow CCF. C and D: AP and lateral view of the post-operative angiogram. Complete occlusion state of the CCF. CCF: carotid cavernous fistulae. ICA: internal carotid artery.

• 

  FIGURE 2 Pre- and post-operative arterial phase of the ICA angiogram in the case 6 patient. A: Pre-operative angiogram shows a prominent left ophthalmic vein, middle cerebral vein, inferior petrosal sinus, and pterygoid plexus. B: Post-operative angiogram shows complete occlusion of the CCF. C: Recurrence of the CCF is noted after the first embolization. D: Complete occlusion of the CCF after the 2nd procedure. CCF: carotid cavernous fistulae.

• 

  FIGURE 3 Pre- and post-operative arterial phase of the ICA angiogram and brain CT perfusion in the case 9 patient. A: Pseudoaneurysm and remarkable venous dilatation of the cavernous sinus including the petrosal sinus and pterygoid plexus is noted. B: Vertebral angiogram with manual compression of both the ICAs showing an aneurysm and fistulous drainage into the cavernous sinus. C: Complete occlusion of the ICA at the level of the aneurysm and complete obliteration of the aneurysm and CCF after the post-operative angiogram. D and F: Postembolization brain perfusion CT was revealed no perfusion defect in both hemisphere (D: Cerebral blood volume image, E: Cerebral blood flow image, F: Mean transit time image). ICA: internal carotid artery.

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