Neurointervention.  2020 Jul;15(2):96-100. 10.5469/neuroint.2020.00094.

Delayed Spontaneous Thrombosis of Neglected Direct Carotid-Cavernous Fistula: A Case Report

• Tiwari S
• Garg PK
• Khera PS
• K.B SB
• Yadav T
• Sureka B

• KMID: 2503396
• DOI: http://doi.org/10.5469/neuroint.2020.00094

Abstract

Direct carotid-cavernous fistula (CCF) refers to direct communication between the cavernous portion of the internal carotid artery (ICA) and the cavernous sinus due to rent in the ICA, most commonly secondary to trauma. These are generally high-flow fistula and rarely resolve spontaneously. We report a case of a young male who developed features of direct CCF after trauma, was denied any treatment for 4 years, and then presented with spontaneous thrombosis of the fistula and a residual large pseudoaneurysm of the cavernous segment of the right ICA, which was subsequently managed with parent vessel occlusion.

Keyword

Fistula; Thrombosis; Pseudoaneurysm

Figure

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  Fig. 1. Magnetic resonance imaging of the brain in May 2018. The axial T2 image (A) and source images of time-of-flight magnetic resonance angiography (B) showed aneurysm dilatation of right cavernous sinus with a dilated superior ophthalmic vein (arrow). Note the prominent right inferior petrosal sinus (C, arrowhead). The imaging feature is consistent with a right-sided direct carotid-cavernous fistula. (D) shows antegrade flow within the distal right supraclinoid internal carotid artery. The axial susceptibility-weighted images (E, F) do not show any cortical venous engorgement.

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  Fig. 2. The non-contrast computed tomography (CT) taken in December 2019 shows a partially thrombosed (arrow) and distended right cavernous sinus (A). The contrast-enhanced CT (B) shows thrombosis (non-opacification) of the right superior ophthalmic vein (double arrows) with a large pseudoaneurysm (asterisk) from the cavernous segment of the right internal carotid artery (ICA). The lateral (C) and antero-posterior (D) projection of the digital subtraction angiogram of the right ICA confirms the pseudoaneurysm of the right ICA (asterisk) with no opacification carotid-cavernous fistula.

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  Fig. 3. The right internal carotid artery (ICA) pseudoaneurysm was managed with partial coiling of the sac (A–C), and subsequent occlusion of the petrous segment of the right ICA. The left ICA injection antero-posterior projection (D) shows good crossflow across the anterior communicating artery to opacify the right ICA circulation. There was no significant venous delay.

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