Endovascular management of the traumatic cerebral aneurysms associated with traumatic carotid cavernous fistulas

Abstract

Background and purpose: Simultaneous traumatic carotid-cavernous fistulas(TCCFs) and traumatic cerebral aneurysms (TCAs) of the internal carotid artery (ICA) are rare. We describe the pitfalls of detecting a TCA before TCCF occlusion and the endovascular management of the TCA and TCCF.

Methods: Over 12 years, 156 patients with TCCFs were treated at our institute. In four men (mean age, 34 years), associated TCAs were detected before (n = 1) or after (n = 3) endovascular occlusion of the TCCFs. Causes for the missed detection of the TCA before TCCF occlusion were masking by a parent artery and fistula drains (n = 1), steal phenomenon (n = 1), and a latent period (n = 1). The TCAs were in the supraclinoid ICA (n = 3) or the paraophthalmic artery (n = 1). Three TCAs were treated with the endosaccular placement of electrodetachable coils.

Results: Two TCCFs and associated TCAs were successfully occluded with preservation of the ICA. The paraophthalmic TCA was treated with coil occlusion of the TCA and TCCF. Spontaneous fatal rupture of the TCA occurred in one patient after subtotal TCCF occlusion. No notable procedure-related complication was observed in the other three patients.

Conclusion: TCAs may be difficult to detect before treatment of the TCCF because it may be overlooked, a latent period may occur, flow may be shunted, or they may be masked by a nearby parent artery or fistula drains. As soon as a TCA is found, endovascular management should be initiated promptly.

Fig 1.

Images in a 49-year-old man with a left TCCF and a TCA of the supraclinoid ICA. A, Left frontal carotid angiogram shows a TCCF with moderate steal phenomenon. The aneurysm was overlooked because of its small size and masking by a nearby parent artery and its venous drains. B, A detachable balloon was placed into the CS with subtotal occlusion of the TCCF. A small TCA about 3 × 2 mm was found at the left supraclinoid ICA (arrow). C, Occlusion of the TCA was achieved by the use of a Guglielmi detachable coil (GDC). Because of the progressive, increased residual fistula flow, the residual TCCF was subsequently obliterated by using GDCs and liquid adhesive, with preservation of the ICA.

Fig 2.

Images in a 40-year-old man with a TCCF and a TCA of the left supraclinoid ICA. A, Left lateral carotid angiogram reveals a TCCF with complete steal phenomenon and no opacification of the supraclinoid ICA or TCA. B, The TCCF was occluded by a detached balloon. A small TCA at the supraclinoid ICA (arrow) was demonstrated and subtotally obliterated with GDCs. C, The patient had a recurrent TCCF due to puncture of the detached balloon; this was eventually occluded by using a detachable balloon, GDCs, and liquid adhesive, with preservation of the ICA.

Fig 3.

Images in a 29-year-old man with a left TCCF and a TCA of the supraclinoid ICA. A, Endovascular occlusion of the TCCF was attempted 3 weeks after trauma. Right lateral postembolization angiogram shows partial occlusion of right TCCF. There is no evidence of the TCA at the supraclinoid ICA because of its latent period. B, Second embolization was performed 2 weeks after the first attempt. A small TCA was initially ignored (arrow) and found after subtotal occlusion of the residual TCCF. However, fatal rupture occurred before an attempt to treat the TCA was made.

Fig 4.

Images in a 19-year-old man with left paraophthalmic aneurysm associated with a TCCF. A, Left carotid angiogram reveals a paraophthalmic TCA (arrow) with rupture into a giant CS varix and draining to the superior ophthalmic vein and inferior petrosal sinus. B, The TCA was subtotally occluded by using GDCs, which also resulted in complete occlusion of the TCCF.