J Cerebrovasc Endovasc Neurosurg.  2024 Dec;26(4):394-398. 10.7461/jcen.2024.E2023.05.001.

Deconstructive repair of a direct carotid-cavernous fistula via a posterior circulation retrograde approach

• Crowe JR
• Regenhardt RW
• Dmytriw AA
• Vranic JE
• Stapleton CJ
• Patel AB

• KMID: 2563088
• DOI: http://doi.org/10.7461/jcen.2024.E2023.05.001

Abstract

We report a case of a 24-year-old patient who presented after a head trauma with a traumatic occlusion of his left internal carotid artery. He underwent diagnostic cerebral angiogram and was found to have a direct left carotid-cavernous fistula (CCF) with retrograde filling from the posterior circulation across the posterior communicating artery. Because of the severe injury to the left internal carotid artery (ICA), reconstructive repair of the ICA was not possible. The patient underwent deconstructive repair of the CCF by coil embolization using a posterior retrograde approach. Coils were successfully placed in the cavernous sinus and back into the left ICA with complete cure of the CCF and restoration of cerebral perfusion distal to the treated CCF. We review the types of CCFs, their clinical presentation, and their endovascular treatments. Retrograde access of a direct CCF is rarely reported in the literature, and we believe this approach offers a viable alternative in appropriately selected patients.

Keyword

Carotid-cavernous sinus fistula; Intracranial embolism; Craniocerebral trauma; Cerebral angiography; Therapeutic embolization

Figure

• 

  Fig. 1. (A) Superior axial view of non-contrast computed tomography of the head showing multi-compartmental intracranial hemorrhage, including predominantly left frontal subarachnoid hemorrhage (arrow). (B) Inferior axial view of non-contrast computed tomography of the head showing extension of subarachnoid hemorrhage into basilar and quadrigeminal cisterns. (C) Axial computed tomography angiography of the head showing asymmetric contrast enhancement in the left cavernous sinus (arrow). (D) Sagittal view of computed tomography angiography of the neck showing occlusion of the left internal carotid artery (arrow). (E) Lateral diagnostic cerebral angiography with contrast injection in the left common carotid artery showing occlusion of left internal carotid artery distal to bifurcation (arrow). (F) Lateral diagnostic cerebral angiography with contrast injection in the left vertebral artery showing CCF filling via the left posterior communicating artery. CCF, carotid-cavernous fistula

• 

  Fig. 2. (A) Digital subtraction lateral view of left vertebral artery contrast injection showing CCF filling via the left posterior communicating artery. (B) Lateral view of left vertebral artery contrast injection after deployment of 1st coil via retrograde approach. The microcatheter was navigated through the basilar artery, left posterior communicating artery, left internal carotid artery, then through the area of injury into the cavernous sinus. Coils were placed in the cavernous sinus and back into the ICA. (C) Lateral view of left vertebral artery contrast injection after deployment of 3rd coil showing diminished CCF. Note the improved distal filling of the anterior cerebral circulation (arrow). (D) Lateral view of left vertebral artery contrast injection after 5th coil showing cure of CCF. The anterior cerebral circulation distal to the CCF continues to improve (arrow). (E) Unsubtracted lateral view of coil placement after treatment. (F) Follow up angiogram after treatment showing complete cure of CCF and improved distal filling of the anterior cerebral circulation (arrow). CCF, carotid-cavernous fistula; ICA, internal carotid artery

Reference

1. Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT. Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg. 1985; Feb. 62(2):248–56.

2. Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Burch JM. Blunt carotid arterial injuries: implications of a new grading scale. J Trauma. 1999; Nov. 47(5):845–53.

3. Biffl CT, Nguyen D, Duc VT, Chau HH, Son VT. Direct traumatic carotid cavernous fistula: angiographic classification and treatment strategies. Study of 172 cases. Interv Neuroradiol. 2014; Jul-Aug. 20(4):461–75.

4. Debrun GM, Ausman JI, Charbel FT, Aletich VA. Access to the cavernous sinus through the vertebral artery: technical case report. Neurosurgery. 1995; Jul. 37(1):144–6. discussion 146.

5. Ellis JA, Goldstein H, Connolly ES, Meyers PM. Carotid-cavernous fistulas. Neurosurg Focus. 2012; May. 32(5):E9.

6. Gemmete JJ, Ansari SA, Gandhi DM. Endovascular techniques for treatment of carotid-cavernous fistula. J Neuroophthalmol. 2009; Mar. 29(1):62–71.

7. Korkmazer B, Kocak B, Tureci E, Islak C, Kocer N, Kizilkilic O. Endovascular treatment of carotid cavernous sinus fistula: A systematic review. World J Radiol. 2013; Apr. 28. 5(4):143–55.

8. Pagiola I, Amaral B, Saito C, Nalli D, Junior HC, Frudit M. Is the retrograde access for endovascular treatment of a traumatic carotid cavernous fistula associated with dissection of the ipsilateral carotid possible? J Cerebrovasc Endovasc Neurosurg. 2021; Mar. 23(1):54–59.

9. Wilms G, Demaerel P, Lagae L, Casteels I, Mombaerts I. Direct caroticocavernous fistula and traumatic dissection of the ipsilateral internal carotid artery: endovascular treatment. Neuroradiology. 2000; Jan. 42(1):62–5.