Direct traumatic carotid cavernous fistula: angiographic classification and treatment strategies. Study of 172 cases

Abstract

We report our experience in treatment of traumatic direct carotid cavernous fistula (CCF) via endovascular intervention. We hereof recommend an additional classification system for type A CCF and suggest respective treatment strategies. Only type A CCF patients (Barrow's classification) would be recruited for the study. Based on the angiographic characteristics of the CCF, we classified type A CCF into three subtypes including small size, medium size and large size fistula depending on whether there was presence of the anterior carotid artery (ACA) and/or middle carotid artery (MCA). Angiograms with opacification of both ACA and MCA were categorized as small size fistula. Angiograms with opacification of either ACA or MCA were categorized as medium size fistula and those without opacification of neither ACA nor MCA were classified as large size fiatula. After the confirm angiogram, endovascular embolization would be performed impromptu using detachable balloon, coils or both. All cases were followed up for complication and effect after the embolization. A total of 172 direct traumatic CCF patients were enrolled. The small size fistula was accountant for 12.8% (22 cases), medium size 35.5% (61 cases) and large size fistula accountant for 51.7% (89 cases). The successful rate of fistula occlusion under endovascular embolization was 94% with preservation of the carotid artery in 70%. For the treatment of each subtype, a total of 21/22 cases of the small size fistulas were successfully treated using coils alone. The other single case of small fistula was defaulted. Most of the medium and large size fistulas were cured using detachable balloons. When the fistula sealing could not be obtained using detachable balloon, coils were added to affirm the embolization of the cavernous sinus via venous access. There were about 2.9% of patient experienced direct carotid artery puncture and 0.6% puncture after carotid artery cut-down exposure. About 30% of cases experienced sacrifice of the parent vessels and it was associated with sizes of the fistula. Total severe complication was about 2.4% which included 1 death (0.6%) due to vagal shock; 1 transient hemiparesis post-sacrifice occlusion of the carotid artery but the patient had recovered after 3 months; 1 acute thrombus embolism and the patient was completely saved with recombinant tissue plaminogen activator (rTPA); 1 balloon dislodgement then got stuck at the anterior communicating artery but the patient was asymptomatic. Endovascular intervention as the treatment of direct traumatic CCF had high cure rate and low complication with its ability to preserve the carotid artery. It also can supply flexible accesses to the fistulous site with various alternative embolic materials. The new classification of type A CCF based on angiographic features was helpful for planning for the embolization. Coil should be considered as the first embolic material for small size fistula meanwhile detachable balloons was suggested as the first-choice embolic agent for the medium and large size fistula.

Keywords: carotid cavernous fistula; contralateral internal carotid artery approach; internal carotid artery ligation; percutaneous cavernous sinus embolization.

Figure 1

CCF with absence of eye symptom. MRI showed dilated cavernous sinus and huge flowvoids of the ecstatic cortical veins which were confirmed by angiography images.

Figure 2

CTA of the brain showed pseudoaneurysm of the left ICA within the cavernous sinus. This patient had massive nose bleeding which need blood transfusion more than 40 pints. The patient was saved with sacrifice of the parent ICA.

Figure 3

Non-contrast CT images showed diffuse subarachnoid hemorrhage in a patient with a history of direct CCF which was treated previously by ICA muscle occlusion 2002. Angiography showed recurrent CCF with multiple cortical vein aneurysm. There was also reflux into the internal cerebral vein, prepontine and spinal veins (white arrow).

Figure 4

Angiography images of a patient with left CCF. There were no correct Pcom artery (which was become fetal Pcom) and there was also hypoplastic left A1 which make less collaterals to the left cerebral hemisphere. DWI image showed acute infarct at the left thalamus and left basal ganglia.

Figure 5

A,B) Agiographic images showed trigeminal artery which was fistulous to the cavernous sinus. (C) The left ICA was hypoplastic. (D) Angiographic image of the left vertebral artery, AP view.

Figure 6

A) (left): Angiographic appearance of the large size CCF. There was cut off of the ICA flow. Reflux of blood to the cavernous sinus and the draining veins. MCA and ACA were absent. (B) (right): cerebral vasculature after balloon detachment.

Figure 7

Angiographical images of the patient who was classified as medium fistula. A and B (upper row): AP and lateral views showing MCA quite clearly and the flow of the ACA is reduced. The flow of ICA to the cavernous sinus is abundant with obviously dilated draining ophthalmic vein and inferior petrosal sinus. C and D (lower row): angiographical images of the patient after balloon embolization. The fistula was totally closed with increase vascularization of the MCA and ACA territories.

Figure 8

Angiography of the small size fistula. (A) (left): before embolization. The fistula (white arrow). The tip of the microcatheter within the cavernous sinus (black arrow). (B) after embolization. Presence of coils within the cavernous sinus and the fistulous site.

Figure 9

Angiography of the recurrence CCF patient 6 months after ligation of the common carotid artery. (A) run from the right subclavian artery showed anastomosis of the right vertebral artery to the occipital branch of the right ECA, going to right ICA and supplying back to the fistula. (B) run from the left vertebral artery showed recurrent right CCF with supply from the right PCA via right Pcom artery. The right ICA was punctured and the fistulous portion of the right ICA was embolized. (C) image of the coils after total occlusion of the fistulous portion of the right ICA. No fistula was seen in the contrasted images.

Figure 10

Angiography of the patient with recurrence CCF after ICA ligation. (A) run from the right ICA showed left CCF supplied from the right ICA via Acom artery. (B) direct left ICA puncture. (C) run from the right ICA after left ICA occlusion using balloons.

Figure 11

Angiogram of the patient with recurrence left CCF after left ICA ligation. The diagnostic angio showed recurrence CCF supplied from the left Pcom and sphenopalatine branch of left ECA (images were not showed). (A) selective cannulation of the left Pcom artery to the cavernous sinus and putting coils. (B) run from the left CCA post embolization of the cavernous sinus showed no more fistula from the ECA branches. Presence of the ICA stump after ligation (arrow). (C) run from the left vertebral artery showed complete occlusion of the left cavernous sinus and fistulous portion of the left ICA (arrow).

Figure 12

A) (left): Angiography from the right ICA after the first balloon embolization which show persistent right CCF with cortical vein reflux and presence of multiple balloons within the right cavernous sinus. The right ICA did not supply the right ACA and right MCA. The right MCA and ACA was supplied from the left ICA. The fistula was also demonstrated from the left ICA run via Acom. (B) (right): Angiography images from the left ICA after the second embolization. The right right ICA was occluded and the fistula was sealed. The right MCA and ACA was also well visualized from the left ICA run.