CASE 10760 Published on 01.06.2013

Endovascular treatment of a post-traumatic carotid-cavernous fistula: a case report

Section

Neuroradiology

Case Type

Clinical Cases

Authors

Vannucci S, Accogli S, Desideri I, Cosottini M, Puglioli M, Bartolozzi C

University Hospital of Pisa, Department of Diagnostic and Interventional Radiology
Patient

49 years, male

Categories
Area of Interest Neuroradiology brain, Arteries / Aorta ; Imaging Technique CT, Catheter arteriography
Clinical History
We report the case of a 49-year-old male that was admitted to the Radiology Emergency Room after a fall with cerebral and facial trauma involving mainly the lateral portion of the right orbit. At physical examination he was confused with a pulsating left exophtalmos.
Imaging Findings
CT study showed a left-side skull-base fracture involving the left carotic channel and a diffuse subarachnoid haemorrhage (Fig 1).
Digital subtraction angiography showed an occlusion of the left extracranial Internal Carotid Artery(ICA) (Fig.2a). Right Vertebral-angiography showed a retrograde opacification of the carotid channel up to the petro-cavernous segment through the posterior communicating artery and the presence of a carotid-cavernous fistula (Fig.2b). The drainage pathway included: ophthalmic vein, inferior petrosal/intercavernous sinus and sylvian vein. The opacification of left the anterior and middle cerebral artery was allowed by anterior communicating artery (Fig.2c).
After placement of a guiding catheter in the left vertebral artery, we reached the petrous portion of the left ICA navigating through the left posterior communicating artery with a microcatheter (Fig.3a). Progressing towards the cavernous portion of the carotid siphon, we progressively detached 10 coils into the sinus (fig.3b), obtaining complete exclusion of the fistula with good opacification of the left carotid circulation through the left posterior communicating artery and anterior communicating artery (Fig. 3c-d).
Discussion
Carotid-cavernous fistulas (CCFs) are abnormal communications between the carotid arterial system and the cavernous sinus. Types-A fistulas [1] are a direct shunt between the intracavernous ICA and the cavernous sinus, often having a traumatic pathogenesis and usually require a treatment. Fistulas can lead to orbital venous congestion, proptosis, eyelid swelling, corneal ulcerations, pulsating exophthalmos, chemosis and compromised retinal perfusion with visual impairment until complete vision loss [2]; in more severe cases large–calibre fistulas can also generate ischemia of large cerebrovascular territories [3]. The imaging findings of a carotid-cavernous fistula include of dilation of the superior ophthalmic vein, enlargement of cavernous sinus, proptosis, and thickness of extraocular muscles; digital angiography (DSA) is the "gold standard" because it can reveal fistulas supplied by the internal carotid artery and its drainage pathway.
The goal of treatment in direct CCFs is to occlude the site of communication between the ICA and the cavernous sinus while preserving the patency of the ICA. The two most diffused endovascular techniques are represented by transarterial obliteration of the fistula with a detachable balloon and coil embolisation. Since detachable balloon and embolisation technique has a high rate of complications, transarterial or transvenous coil embolisation has become the mainstay of endovascular treatment of direct CCFs. The standard transarterial approach consists of placing a guiding catheter in the common carotid artery and advancing a microcatheter into the cavernous segment of the ICA. The microcatheter is selectively advanced toward the tear into the cavernous sinus. Embolic material such as detachable platinum coils can be delivered into the cavernous sinus although liquid embolic agents such as n-BCA or Onyx may also be used to occlude the fistula.
Potential complications of endovascular treatments are thromboembolic and ischemic events related to the balloon and the catheter manipulation: formation of pseudoaneurysms, arterial hemodynamic changes causing haemorrhage, oedema and progression of ocular damage [3, 4].
In our case, a direct post-traumatic CCF with internal carotid artery transection, we have excluded the standard transarterial approach for the presence of complete occlusion of the left internal carotid artery above the carotid bulb; also the transvenous route was excluded because of the complexity due to the drainage of the fistula in the left superior ophthalmic vein. We opted to reach the site of the fistula through the posterior circulation thanks to the presence of a hypertrophic left posterior communicating artery choosing detachable platinum coils as embolic material for the possibility of precise positioning and a well-controlled detachment.
Differential Diagnosis List
Traumatic type A carotid-cavernous fistula
Malignancy of the orbit
Arterovenous malformations of the orbit/cavernous sinus
Retrobulbar bleeding
Cavernous sinus thrombosis
Final Diagnosis
Traumatic type A carotid-cavernous fistula
Case information
URL: https://www.eurorad.org/case/10760
DOI: 10.1594/EURORAD/CASE.10760
ISSN: 1563-4086