Vasospasm in the setting of traumatic bilateral carotid-cavernous fistulas and its effect on treatment

Abstract

Background: Direct, Type A, cavernous-carotid fistulas (CCFs) are predominantly caused by head trauma, especially when basilar skull fractures are present. Transarterial endovascular treatment of direct CCFs is the preferred method of treatment. Bilateral CCFs are estimated to be present in 1-2% of the cases. The treatment of bilateral CCFs is difficult often requiring a combination of endovascular and open surgical approaches.

Case description: We present a case of traumatic bilateral CCFs presenting with vasospasm of the anterior circulation seen on the initial angiogram on day 1 and our treatment paradigm.

Conclusion: This case illustrates the challenges in managing bilateral CCFs as well as the changes in collateral circulation because of cerebral vasospasm which affected our treatment paradigm.

Keywords: Caroticocavernous fistula; carotid cavernous fistula; cerebral vasospasm; head trauma; traumatic subarachnoid hemorrhage.

Figure 1

(a) Anterior-posterior and lateral cerebrocervical angiograms of right ICA injection showing right ICA dissection and CCF near the petrous and cavernous portion of the right ICA without drainage into the superior ophthalmic vein or into the inferior petrosal sinus. (b) Angiogram of left ICA injection on day 1 of admission and angiogram of right ICA injection on day 21. There is vasospasm of the left A1 segment near its origin on day 1 which resolved by day 21

Figure 2

Follow-up head CT on the day of admission shows extensive SAH as well as an epidural hematoma that required evacuation

Figure 3

(a) Lateral cerebral angiogram of right ICA injection showing early venous drainage through the right CCF with retrograde filling of the right SOV. Note evidence of vasospasm along the right communicating portion of the ICA and the right M1. (b) Anterior-posterior cerebral angiogram of left ICA injection showing no flow into the left ACA due to severe vasospasm of the left A1 segment and mild to moderate vasospasm of the left ICA and M1 segment of the left MCA. (c) Anterior-posterior cerebral angiogram of right ICA injection showing mild vasospasm of the right ICA and M1 segment of the right MCA. There is no evidence of retrograde cortical venous drainage

Figure 4

Anterior-posterior cerebral angiogram of right ICA injection after left ICA and left cavernous sinus occlusion showing antegrade flow into both anterior circulation. The venous phase on the left was delayed by 1 second compared to the right side. There continues to be evidence of retrograde cortical venous drainage from the right cavernous sinus into the right superficial middle cerebral vein

Figure 5

(a) Microscope photograph showing the arterialized right superficial middle cerebral vein. (b) Microscope photograph showing the right superficial middle cerebral vein after it was clipped, cauterized, and cut

Figure 6

Three-month follow-up anterior-posterior cerebral angiogram of right ICA injection reveals good collateral flow into the left anterior circulation via the Acomm with retrograde flow through the residual left CCF into the cavernous sinus