Neurointervention.  2019 Mar;14(1):63-67. 10.5469/neuroint.2018.01102.

Objective Assessment of Arterial Steal Phenomenon in Direct Carotid Cavernous Fistula Using 2D Parametric Parenchymal Blood Flow Analysis

• Elsaid N
• Saied A
• Joshi K
• Nelson J
• Baumgart J
• Lopes D

• KMID: 2446784
• DOI: http://doi.org/10.5469/neuroint.2018.01102

Abstract

The aim of the study is to evaluate the hemodynamic changes and the parenchymal perfusion associated with carotid cavernous fistulas before and after embolization using two-dimensional (2D) parenchymal blood flow analysis. A 15-year-old boy presented with 2-month history of progressive right eye proptosis, chemosis, and diplopia after a motor vehicle accident. Intracranial liquid embolization using Onyx-18 through the inferior petrosal approach was done with balloon protection at the opening of the fistula in the internal carotid artery, resulting in complete occlusion of the fistula. Parenchymal blood flow analysis was done before and immediately after embolization. 2D parametric parenchymal blood flow analysis is newly introduced software that can provide data cannot be conveyed by conventional digital subtraction angiography alone. The software allows for objective assessment of the arterial steal and the parenchymal perfusion both pre, and post-embolization. Pre-embolization assessment may influence the therapeutic decision, while post-embolization assessment can evaluate the treatment efficacy.

Keyword

Hemodynamics; Steal phenomenon; Fistula; Internal carotid artery; Embolization, Therapeutic; Software

MeSH Terms

Adolescent
Angiography, Digital Subtraction
Carotid Artery, Internal
Diplopia
Embolization, Therapeutic
Exophthalmos
Fistula*
Hemodynamics
Humans
Male
Motor Vehicles
Perfusion
Treatment Outcome

Figure

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  Fig. 1. Pre and post-embolization angiographic images. (A) Pre-embolization lateral view, (B) post-embolization lateral view, (C) pre-embolization antero-posterior view, (D) post-embolization antero-posterior view; showing complete occlusion of the fistula.

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  Fig. 2. Position of ROIs during parametric blood flow ‘wash-in-rate’ measurement; ROI 1 placed along the MCA territory, ROI 2 placed along ACA territory. (A) Pre-embolization lateral view, (B) post-embolization lateral view, (C) pre-embolization antero-posterior view, (D) post-embolization antero-posterior view; showing remarkable changes in the ‘wash-in-rate’ color code after embolization.

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  Fig. 3. ‘Wash-in-rate’ color code in the non-affected side antero-posterior view. (A) Pre-embolization, (B) post-embolization showing mild and less marked changes in the ‘wash-in-rate’ color code after embolization relative to the affect- A B ed side.

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