Traumatic cerebral aneurysm associated with a contralateral traumatic carotid cavernous fistula. A case report

Abstract

This report documents the management of a traumatic carotid aneurysm (TCA) with a traumatic carotid-cavernous fistula (T-CCF) of the contralateral internal carotid artery (ICA) following a closed head injury. A 38-year-old man presented with severe traumatic subarachnoid hemorrhage and pneumocephalus due to a severe head injury. Four months after the accident, the patient presented with clinical symptoms of exophthalmos and retroorbital bruit. Cerebral angiography showed a TCA of the IC-PC region, which coexisted with a contralateral T-CCF. Both lesions were successfully managed with an endovascular treatment using coils to isolate a fistula from the ICA, and direct surgical trapping of the intracranial ICA to eliminate a TCA. Post-operative angiography revealed a good cross-flow through the anterior communicating artery from the contralateral ICA, which was completely obliterated by the T-CCF. No additional surgical or endovascular procedure for traumatic vascular injuries was required. The patient remained asymptomatic during the clinical follow-up period of 24 months. The goal of traumatic carotid injuries is the selective elimination of the vascular pathologic injury with asymptomatic state, using direct surgery and/or an endovascular treatment.

Figure 1

Preoperative left CA angiograms. Upper left: Anteroposterior view demonstrating of a good cross-filling of the right MCA territory. Upper right: Lateral view revealing a traumatic carotid-cavernous fistula, which was mainly drained into superior orbital vein. Lower left and right: preoperative 3D left CA angiograms demonstrating the orifice of fistula clearly.

Figure 2

Preoperative right CA angiograms. Above: early (upper left) and late (upper right) phases of lateral view demonstrating aneurysm of internal carotid -posterior communicating artery, which showed the delayed filling of the sac. Lower left: anteroposterior view with compression of the left cervical CA revealing the orifice of T-CCF. Lower right: 3D angiogram showing the orientation of the origin of the right posterior communicating artery.

Figure 3

Left: A microcatheter (Renegade) through the left facial vein delivering GDC. Center and Right: anteroposterior (center) and lateral (right) view of left CA angiograms obtained after GDC embolization, demonstrating complete obliteration of T-CCF.

Figure 4

Above: Intraoperative photographs showing the crack of the right CA after clipping (upper left), followed by trapping (upper right). Below: Photomicrographs showing no collagaenous fiber, without arterial wall component (hematoxylin and eosin stain, original magnification x100 (lower left) and x400 (lower right).

Figure 5

Postoperative left CA angiograms. Early (left) and late (right) phase of anteroposterior view with compression of the right cervical CA revealing a good cross-filling of the right MCA territory.