ABSTRACT
Objective: To review Siriraj Hospital’s experiences with direct surgical treatment of complicated traumatic carotid-cavernous fistulas (CCFs) in the context of multidisciplinary approach. Methods: This study is a retrospective review of complicated direct carotid cavernous fistulas (CCFs) that had opened surgery after failure of detachable balloon embolization. Data were collected from medical records, radio-angiographic records, and follow-up results of combinations of treatment. Results: From 1993- April 2003, we have total 25 cases of combined surgery and endovascular treatment of traumatic carotid-cavernous fistulas (CCFs). Causes of unsuccessful balloon embolization are small-hole fistula, deflation of the balloon, difficult position of fistula, false aneurysm, risk of intracavernous internal carotid artery (ICA) occlusion, and tortuosity of ICA and draining veins. Various procedures were performed and all patients have good results with completed resolution of clinical triad symptoms. On follow-up cerebral angiography of 16 patients that received cavernous sinus packing, we could preserve the patency of ICA in 8 patients but 5 patients had thrombosis of ICA without ischemic events. In 3 patients, an operation to occlude the ICA was performed after failure of cavernus sinus packing. Conclusions: The standard treatment of carotid cavernous fistula is endovascular balloon embolization. When the endovascular treatment fails, surgical packing of cavernous sinus is immediately considered an alternative way to cure the CCFs and to offer additional technique to help increase the patency of ICA.
ABSTRACT
This retrospective study analysed the data regarding the operative outcome of patients who had subarachnoid hemorrhage (SAH) from rupture of a saccular aneurysm of the anterior cerebral circulation. All patients were operated on by the author between July 1997 and November 2001 at Siriraj Hospital. A total of 62 patients were included in this study. All patients were assessed on admission using Hunt and Hess classification. There were 5 patients (8.1%) in Grade 1, 12 patients (19.4%) in Grade 2, 37 patients (59.7%) in Grade 3, 7 patients (11.3%) in Grade 4, and 1 patient (1.6%) in Grade 5. A uniform management protocol was used in every patient including intensive cardiovascular monitoring, calcium channel blocker administration, early surgery clipping the aneurysm and aggressive anti-ischemic treatment. There were 22 patients (35.5%) who received early surgery (within 72 hours of the SAH), 12 patients (19.4%) received intermediate surgery (between Day 4 and day 6 following SAH) and 28 individuals (45.1%) had late surgery (Day 7 or later following SAH). At 6 months after the SAH, favorable outcome (Glasgow Outcome Scale: GOS 1 and 2) was achieved in 55 patients (88.7%), unfavorable outcome (GOS 3 and 4) in 1 patient (1.6%) and death in 6 patients (9.7%). The causes of death were surgically related in 3 patients (4.8%) and non-surgically related (delayed ischemic complication and sepsis) in 3 patients (4.8%).