Traumatic Carotid-cavernous Fistula with Contralateral Proptosis: Case Report

Traumatic carotid-cavernous fistula frequently results in proptosis on the side of the fistula by retrograde drainage from the cavernous sinus to the superior ophthalmic vein. The involvement of the opposite orbit is due to the presence of connections between the cavernous sinuses on both sides, but exclusive contralateral orbit involvement is rare. We report a case in which the CCF with a contralateral proptosis developed in a 63 year-old man after a motor vehicle accident. MR angiography depicted the markedly dilated left cavernous sinus and left superior ophthalmic vein, sparing the right side. However, angiography showed a direct fistula between the right internal carotid artery and cavernous sinus with exclusive contralateral venous drainage via the intercavernous sinus. A detachable balloon was used to occlude the fistula, and the contralateral orbital symptom regressed.

Helical CT Finding of Carotid-Cavernous Fistula: A Sign of Early Enhancing Superior Ophthalmic Vein

PURPOSE: The purpose of this study was to determine the diagnostic value of a sign of early enhancing superior ophthalmic vein (SOV), as seen on helical CT images in patients with carotid-cavernous fistula (CCF). MATERIALS AND METHODS: This study involved 16 patients with CCF and 28 control patients. Axial CT images with scanning delays of 30 seconds following bolus injection of contrast material (90 mL, 3 mL/sec) were obtained, and this procedure was followed by coronal CT imaging. To determine the presence or absence of early enhancement or, dilatation of the SOV, bulging of the cavernous sinus, and enlargement of extraocular muscle, CT images were analysed by three observers in a blinded, random manner. Early enhancement of SOV was determined to be present where enhancement of the SOV was similar to or stronger than that of the ipsi-lateral posterior cerebral artery. RESULTS: A sign of early enhancing SOV was seen in 14 of the 16 patients with CCF but in no control patients (88% sensitivity and 100% specificity). The respective sensitivity and specificity of other CT features were 71% and 100% (dilatation of the SOV, as seen on axial images), 60% and 83% (dilatation of the SOV, as seen on coronal images), 71% and 89% (dilatation of the cavernous sinus), and 65% and 98% (enlargement of extraocular muscle). CONCLUSION: A sign of early enhancing SOV is a characteristic and specific CT finding of CCF, and is useful for the diagnosis of CCF.

Endovascular Treatment of Direct Carotid Cavernous Fistulas Using Detachable Balloon(s) and Coils

PURPOSE: To evaluate the merits of this technique and to provide a standard for comparison with futuretreatment alternatives. MATERIALS AND METHODS: We retrospectively reviewed the records of 52 patients withdirect CCF treated at the Yonsei Medical Center between 1983 and 1997 by transarterial or transvenous embolizationusing detachable balloon(s) and/or coils. RESULTS: Among the 52 cases, 51 were traumatic in origin, while onlyone was the result of a ruptured aneurysm. The three most common presentations were chemosis, bruit, andpulsatile proptosis. Forty-five patients were successfully treated with detachable balloon(s) and/or coils andinternal carotid blood flow was preserved in 35. When coils were used (1993-7), the ICA preservation rate washigher than when they were not used (1983-92). To confirm statistical significance, however, more studies areneeded. Four patients who initially presented with incomplete occlusion showed spontaneous occlusion on follow upangiography. In two patients, surgical ligation was performed because embolization failed and there was incompleteocclusion of the fistula. We experienced complications such as transient 3rd and 6th cranial nerve palsy,migration of deflated balloons and coils to the lung, and loss of vision. CONCLUSION: Transarterial andtransvenous embolization with detachable balloon(s) and/or coils provides a high rate of fistula obliteration withlow morbidity. In particular, the use of coils led to an increased rate of ICA preservation, thus and isconsidered as a good treatment modality for CCF obliteration.

The Results of Embolization of Dural Arteriovenous Fistula

PURPOSE: To assess the embolization effect of dural arteriovenous fistula(DAVF). MATERIALS AND METHODS: Weevaluated 23 patients with DAVF who were diagnosed using digital subtraction angiography and treated bytransarterial and/or transvenous emobolization. The locations of DAVFs, as seen on angiography were as follows: 16in the cavernous sinus, four in the major dural sinuses, two in the jugular bulb, one in the torcula Herophili,and one in the tentorium cerebelli. On the basis of venous drainage patterns, Cognard's classification of DAVF wasused. Among our 23 patients, 13 underwent transarterial embolization, six underwent transvenous embolization, andfour underwent both. After embolization, three patients underwent other treatment: surgery, one ; gammairradiation, one ; and both. One. Polyvinyl alcohol particles or glue was used in transarterial embolization, andtungsten, platinum, or Guglielmi detachable coils in transvenous embolization. To analyse the residual lesion inDAF, we compared pre- and post-treatment angiograms ; patients were followed up for 2 to 48 months, and theircondition was assessed as cured, improved, not changed, or aggravated. RESULTS: Nine patients were found to beCognard type I, two were IIa, four were IIa+b, and eight were type III. Of our 23 patients, 12 were cured, tenimproved, and one was aggravated ; of the 13 who underwent transarterial embolization, four were cured, eightimproved, and one was aggravated ; of the six who underwent transvenous embolization, five were cured and oneimproved. The condition of a patient with a lesion in the torcular herophili was aggravated despite surgery andgamma irradiation after embolization. CONCLUSION: DAVF can be managed successfully with endovascular treatment.The outcome of the transvenous approach appears to be better than that of the transarterial approach alone. In acase involving a lesion in the torcular herophili, the outcome was poor and more aggressive treatment wasrequired.