• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.3
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• pp.245-252
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• 2023

Carotid-cavernous fistulas, characterized by abnormal arteriovenous communication within the cavernous sinus (CS), can be classified as direct or indirect. Direct fistulas are defined as a direct connection between the internal carotid artery (ICA) and CS, whereas indirect fistulas result from an abnormal connection between the CS and dural arterial branches. The first-line treatment for both types of fistulas is endovascular intervention, most commonly accomplished through the transarterial and transvenous approaches of the conventional pathway, including the ICA, inferior and superior petrosal sinuses, or basilar plexus. Nonetheless, a retrograde approach through the superior ophthalmic vein may be necessary for individuals in whom conventional endovascular treatment fails. Herein, the current principles of surgical indication and technique are presented, along with case studies.

• Journal of Korean Neurosurgical Society
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• v.46 no.6
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• pp.572-576
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• 2009

Detachable balloon-based endovascular fistula occlusion is a widely accepted treatment for traumatic carotid cavernous fistulas (CCF). However, more recently coils have been used to obliterate the lesion, especially in case detachable balloon is not available. We failed balloon-assisted coil embolization for CCF because of large fistulas and herniation of coil loops into the parent artery. The authors describe our experiences of balloon-expandable graft-stents to treat CCF, and place emphasis on arterial wall reconstruction. Three traumatic CCF patients were treated using a graft-stent with/without coils, and underwent angiographic follow-up to evaluate the patency of the internal carotid artery (ICA). In all cases, symptoms related to CCF regressed after stent deployment and did not recur during follow-up. Follow-up angiography revealed good patency of the ICA in all patients. Graft-stents should be considered as an alternative means of treating CCF and preserving the parent artery by arterial wall reconstruction especially in patients with a fistula that cannot be successfully occluded with detachable balloons or coils.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.3
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• pp.306-310
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• 2023

Traumatic internal carotid artery injuries can produce direct carotid-cavernous fistulas as well as giant internal carotid artery pseudoaneurysms. Clinical sequelae can include headaches, cranial nerves palsies, proptosis, chemosis and optic neuropathy with visual loss as the most dangerous complication. Herein, we present a case of one of the largest reported internal carotid artery pseudoaneurysms associated with a direct carotid cavernous fistula. We describe the techniques and pitfalls of treatment with parent vessel occlusion.

• Archives of Craniofacial Surgery
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• v.11 no.2
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• pp.116-119
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• 2010

Purpose: Arteriovenous fistulas that involve the cavernous sinus often produce ophthalmologic symptoms and signs. Transvenous endovascular access is the method of choice for a carotid-cavernous sinus fistula. The superior ophthalmic vein is a safe and reasonable alternative route for the transvenous embolization of carotid-cavernous sinus fistula. We report a case of the embolization of a carotid-cavernous sinus fistula using the superior ophthalmic vein approach. Methods: A 58 year old female had conjunctival congestion, periocular pain and diplopia with a 2 month duration. Diagnostic orbital CT, brain MRI and cerebral angiography revealed a carotid-cavernous sinus fistula. The fistula occlusion was treated by coil embolization using the superior ophthalmic vein approach. Results: The initial presenting symptoms, conjunctival congestion, periocular pain and diplopia, decreased after surgery. Coil embolization via the superior ophthalmic vein approach was difficult because of the venous tortuosity and friability. During the follow up period, the patient was in a good condition without complications. Conclusion: Surgical exposure of the superior ophthalmic vein provides direct venous access to the cavernous sinus as well as an effective and safe treatment approach. The cooperation of the plastic surgeon and interventionist is a factor in successful treatment.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.22 no.2
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• pp.243-248
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• 2000

Carotid cavernous sinus fistula(CCSF) is an abnormal communication at the base of the skull between the internal carotid artery and the cavernous sinus. Fistula is almost associated with extensive facial trauma as a result of direct or indirect forces. Most fistulas of traumatic origin develop as a result of fractures through the base of the skull, which cause the laceration of the internal carotid artery near the cavernous sinus. The signs and symptoms of CCSF are pulsating exophthalmosis, orbital headache, pain, orbital or frontal bruit, loss of visual acuity, diplopia and ophthalmoplegia. Angiography reveals a definite CCSF and a detachable balloon embolization is known to be the treatment of choice. Even though carotid cavernous sinus fistula is an uncommon complication after orthognathic surgery, several cases of CCSF due to congenital anomalies, pre-existing aneurysms and abnormally thickened maxillary posterior wall have been reported in the literature. We have experienced a case of CCSF after Le Fort I osteotomy for maxillary advancement in skeletal class III patient and the cause, pathogenesis, diagnosis and treatment of this case.

• Journal of Yeungnam Medical Science
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• v.6 no.2
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• pp.91-101
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• 1989

The goal of therapy in patients with traumatic carotid-cavernous fistulas is to occlude the fistula, preferably while maintaining the carotid blood flow. Since the introduction of the concepts of detachable balloon technique to occlude arteriovenous fistulas, the technique has become the treatment of choice in the management of traumatic carotid-cavernous fistulas. The major symptoms of traumatic CCFs are (1)pulsating exophthalmos, (2)orbital and cephalic bruit and murmur, (3) headache, (4) chemosis. (5) extraocular palsies, and (6) visual failure. Traumatic CCFs are combined with multiple associated lesions. We tried the occlusion of fistulas using Goldvalve balloons in 8 consecutive cases of traumatic CCF and the result of our experience is reported. Transarterial approach with manually-tied latex balloons is tried in all cases and the fistulas was successfully occluded in all cases. In 5 cases. the internal carotid artery was preserved and the arterial lumen was occluded along with fistula opening in :3 cases. In one case, surgical ligation was done because of symptoms recurred and incomplete occlusion of fistula. We experienced hemiparesis as a major complication in one case during occlusion tolerance test, which was remitted spontaneously. The results of Debrun balloon treatment were relatively excellent. We consider that the first choice of treatment of traumatic CCF is occlusion of the fistula by a detachable balloons.

• Journal of Korean Neurosurgical Society
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• v.57 no.1
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• pp.12-18
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• 2015

Objective : Covered stent has been recently reported as an effective alternative treatment for direct carotid cavernous fistulas (DCCFs). The purpose of this study is to describe our experiences with the treatment of DCCF with covered stents and to evaluate whether a covered stent has a potential to be used as the first choice in selected cases. Methods : From February 2009 through July 2013, 10 patients underwent covered stent placement for a DCCF occlusion. Clinical and angiographic data were retrospectively reviewed. Results : Covered stent placement was performed for five patients primarily as the first choice and in the other five as an alternative option. Access and deployment of a covered stent was successful in all patients (100%) and total occlusion of the fistula was achieved in nine (90%). Complete occlusion immediately after the procedure was obtained in five patients (50%). Endoleak persisted in five patients and the fistulae were found to be completely occluded by one month control angiography in four. The other patient underwent additional coil embolization by a transvenous approach. Balloon inflation-related arterial dissection during the procedure was noted in two cases; healing was noted at follow-up angiography. One patient suffered an asymptomatic internal carotid artery occlusion noted seven months post-treatment. Conclusion : Although endoleak is currently a common roadblock, our experience demonstrates that a covered stent has the potential to be used as the first choice in DCCF; this potential is likely to increase as experience with this device accumulates and the materials continue to improve.

• Journal of Korean Neurosurgical Society
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• v.64 no.5
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• pp.818-826
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• 2021

Objective : The widely accepted treatment option of a traumatic carotid cavernous fistula (TCCF) has been detachable balloon or coils based fistula occlusion. Recently, covered stent implantation has been proving an excellent results. The purpose of this study is to investigate our experiences with first line choice of covered stent implantation for TCCF at level 1 regional trauma center. Methods : From November 2004 to February 2020, 19 covered stents were used for treatment of 19 TCCF patients. Among them, 15 cases were first line treatment using covered stents. Clinical and angiographic data were retrospectively reviewed. Results : Procedures were technically successful in all 15 cases (100%). Immediate angiographic results after procedure were total occlusion in 12 patients (80%). All patients except two expired patients had image follow-up (mean 15 months). Recurred symptomatic three patients underwent additional treatments and achieved complete occlusion. Mean clinical follow-up duration was 32 months and results were modified Rankin Scale 1-2 in five, 3-4 in five, and 5 in three patients. Conclusion : The covered stent could be considered as fist line treatment option for treating TCCF patients especially in unstable vital sign. Larger samples and expanded follow-up are required to further develop their specifications and indications.

• Journal of Korean Neurosurgical Society
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• v.63 no.4
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• pp.532-538
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• 2020

Traumatic arteriovenous fistulas (AVFs) involving the external carotid artery are exceedingly rare in young adults. Since an AVF is the most common life-threatening cause for pulsatile tinnitus (PT), meticulous evaluation and treatment of patients with PT is crucial. Here, we present two traumatic AVF cases treated with coil embolization leading to no residual fistulous connections followed by an immediate and complete resolution of PT. A 20-year-old man developed left ear tinnitus three months after a traumatic brain injury involving the right temporal bone fracture. Cerebral angiography demonstrated an enlarged left middle meningeal artery (MMA) and a fistular point at the posterior branch of the MMA draining to the middle meningeal vein (MMV) and the left pterygoid plexus, suggesting an AVF. Another 18-year-old girl developed left tinnitus, left exophthalmos, and conjunctival injection 6 months after a traffic accident involving no demonstrable abnormal findings in the radiologic exam. Magnetic resonance angiography demonstrated a markedly dilated left MMA draining to the MMV, left cavernous sinus, and left superior ophthalmic vein. In both cases, coil embolization was performed with total obliteration of the fistular point.