Endovascular treatment of carotico-cavernous fistulas with acrylic glue: a series of nine cases

Abstract

Introduction: Injuries to the internal carotid artery close to the cavernous sinus may result in a fistulous connection between the artery and the venous sinus. Symptoms include pulsatile tinnitus, intracranial bruit, ophthalmological symptoms, and risk of intracerebral hematoma in cases of cortical venous reflux. Previous treatment strategies have included detachable latex balloons, coils, covered stents, or combinations thereof. Today, detachable latex balloons are phased out or withdrawn from several markets. Acrylic glue is a proven stable material used for embolization of arteriovenous shunts. It is a precise, fast, and cost-effective method of endovascular embolization, and it does not cause artifacts on MRI or MRA.

Methods: We treated nine patients suffering from direct fistulas with acrylic glue without any permanent neurological adverse events.

Results: Four patients were treated with glue embolization of the fistula without occlusion of the parent artery. Five patients with long-lasting symptomatology, large tears in the ICA, and with full collateral cerebral circulation were treated with glue embolization of the fistula and sacrifice of the ICA antero- and retrograde via the ICA and the posterior communicating artery.

Conclusion: We suggest acrylic glue to be added to the panel of embolic materials used to treat CCFs.

Keywords: Carotico-cavernous fistula; Cavernous sinus; Collagen disease; Ehlers-Danlos; NBCA.

Fig. 1

33-year old female patient with Ehlers-Danlos syndrome and right-sided spontaneous direct CCF, presenting with pulsatile exophthalmus, conjunctival hyperemia and history of a right-sided temporal hematoma. a Right ICA injection demonstrating a direct CCF with cortical venous reflux as superior ophthalmic artery and inferior petrosal sinus drainage. b, c: Three precise NBCA injections (two are here shown) into the cavernous sinus at the point of drainage of the fistula seals it shut. d Post-operative right ICA injection. The fistula is obliterated and the ICA kept patent. No distal emboli are seen and the cortical venous reflux is suppressed. The patient improved and normalized after embolization.

Fig. 2

16-year old male patient suffering a complex compound skull base fracture after a motor vehicle accident (CT-scan, a), presenting with 1-month history of pulsatile exophthalmus. b Initial DSA demonstrates high-flow CCF with prominent venous hypertension. c With a precise NBCA injection in the cavernous sinus at the fistulous point, the CCF is closed. d Late follow-up control angiogram demonstrating full occlusion of the CCF, patent ICA, and the classical pouch often seen at the fistulous communication after cure. The small residual pouch seen in panel d did not warrant further treatment.

Fig. 3

86-year old lady with a 4-month history of conjunctival hyperemia and intracranial bruit without any known triggering factor. a Angiogram reveals a high-flow right-sided CCF draining towards the inferior petrosal sinus and ophthalmic veins responsible for orbital venous congestion (d). b A targeted NBCA injection at the fistulous point in the cavernous sinus obliterated the fistula. c 3-month post-operative MRA demonstrating patency of the ICA and disappearance of the pathological venous drainage. Clinical appearance of the right eye prior to (d) and at 24-h post-embolization (e).

Fig. 4

24-year old male patient with no clear head trauma recorded presented with a year-long history of pulsatile tinnitus and right sixth nerve palsy. a, b Preoperative MRI and MRA depicting right-sided CCF and a dilated cavernous sinus. DSA (not shown) excluded a ruptured intracavernous carotid aneurysm. It confirmed a CCF with a large tear in the ICA, draining posteriorly to the inferior petrosal sinus, with no direct supply to the ipsilateral hemisphere but adequate collateral circulation via anterior and posterior communicating arteries. Because of the suspicion of collagen disease and subsequent risks of balloon manipulation, it was decided to occlude the CCF by sacrificing the ICA. Glue injections were performed via the posterior communicating artery (c) and the intracavernous segment of the ICA (d), which sealed the CCF and occluded the ICA. e, f 1-month post-operative MRI and MRA demonstrating obliteration of the fistula and ICA. The patient reported full remission of symptoms. Note absence of MRI/MRA imaging artifacts after treatment with NBCA.

Fig. 5

50-year old female patient without previous history of head trauma presented with 3-year history of secondary orbital and facial venous congestion (a) related to a left-sided high-flow CCF draining towards the superior ophthalmic vein, as superficial and deep cortical veins (b). Left vertebral artery injection (c) and left internal carotid artery injection (d) confirmed the fistulous communication. Because of the suspicion of underlying collagen disease and the risks of balloon manipulation, the circulation to the ipsilateral hemisphere being brought by collateral circulation, it was decided to sacrifice the carotid artery and occlude the fistula by glue injections via the internal carotid (e) and the posterior communicating arteries (not shown). f: post-operative MRA 24 h after embolization confirmed obliteration of the fistula and ICA with collateral flow to the left hemisphere via the anterior communicating artery. g Orbital and facial venous dilatations resolved after treatment (clinical appearance 5-day post-embolization), a slight 6th nerve palsy was present, which fully resolved after a few additional days.