Treatment of traumatic carotid-cavernous fistula

Abstract

From 1986 to the end of 1998, 482 cases of traumatic carotid-cavernous fistula (TCCF) were treated by means of intravascular embolisation technique. The experience is overviewed in this article. Many kinds of detachable balloon catheters (including Chinese made detachable balloon catheters), coils and cyanoacrylate were used as embolic materials. Transcervical, transfemoral, anterior communicating artery, posterior communicating artery approach, or transvenous approach were selected according to conditions. A combination of different approaches or materials was used for complex TCCF. We found that the special sign, named "bileakage sign", indicated multileakage of TCCF and was not mentioned before.All 482 cases of TCCF were embolised successfully, of which 405 cases maintained the patency of internal carotid artery (ICA). No death related to the treatment occurred in our group and the symptoms or signs in 462 cases were relieved after embolisation. Emergency embolisation was needed in some conditions such as serious epistaxis, delayed or repeatedly subdural haematoma and rapid visual impairment. Endovascular treatment of TCCF is a safe and efficient method. The time of operation, approach, and materials for embolisation must be carefully selected in order to obtain the best result.

Figure 1

Thirty-year old male, suffered of TCCF. The fistula was embolised with two balloons by transcervical approach.

Figure 2

Thirty-year old male, suffered of TCCF. The fistula could not be occluded completely with balloon. The internal carotid artery was then occluded. But fistula could still be seen by contralateral carotid angiogram. And then we delivered the micro-catheter into cavernous sinus through inferior petrosal. Cavernous sinus was embolised with coils. Finally, fistula was conformed to be embolised by contralateral carotid angiogram.

Figure 3

A 26-year-old male suffered of TCCF with severe epistaxis. Angiogram could show the sign of pseudoaneurysm protruding into sphenoid sinus (A, B). Trying to occlude internal carotid artery could not embolise the fistula completely and epistaxis could not be stopped. Fistula was supported by anterior and posterior communicating artery (C, D). The microcatheter was introduced into fistula through posterior communicating artery. The fistula was totally embolised by MDS (E, F). Contralateral carotid artery and vertebral artery angiogram showed the good result of embolisation (G, H).

Figure 3

A 26-year-old male suffered of TCCF with severe epistaxis. Angiogram could show the sign of pseudoaneurysm protruding into sphenoid sinus (A, B). Trying to occlude internal carotid artery could not embolise the fistula completely and epistaxis could not be stopped. Fistula was supported by anterior and posterior communicating artery (C, D). The microcatheter was introduced into fistula through posterior communicating artery. The fistula was totally embolised by MDS (E, F). Contralateral carotid artery and vertebral artery angiogram showed the good result of embolisation (G, H).

Figure 4

A 37-year-old male, suffered from left TCCF. The fistula could not be occluded with the patency of ICA (A, B). The ICA had to be occluded together with the fistula (C, D). The angiograms of vertebral artery and contralateral carotid artery showed the compensatory blood supply of the occluded ICA (E, F).

Figure 5

A 45-year-old male, suffered from TCCF. The fistula was too small to pass the balloons. So we had to embolised the fistula with 2 sets of GDC.

Figure 6

A 29-year-old male, suffered from TCCF. It was occluded with coils in other hospital, but it reoccurred (A). We re-embolised the fistula with balloon, the coils used by other hospital was also seen (B). But the fistula could not be totally occluded (C). The fistula reoccurred again (D). The fistula was again embolised with NBCA, but it was only partially occluded (E). The fistula was nearly totally occluded 3 days after the NBCA occlusion (F). The patient refused the DSA recheck. But no sign of fistula occurred in 4 years.

Figure 6

A 29-year-old male, suffered from TCCF. It was occluded with coils in other hospital, but it reoccurred (A). We re-embolised the fistula with balloon, the coils used by other hospital was also seen (B). But the fistula could not be totally occluded (C). The fistula reoccurred again (D). The fistula was again embolised with NBCA, but it was only partially occluded (E). The fistula was nearly totally occluded 3 days after the NBCA occlusion (F). The patient refused the DSA recheck. But no sign of fistula occurred in 4 years.

Figure 7

Bileakage sign.