Combined surgery and endovascular treatment of complicated traumatic carotid-cavernous fistulas: Results and illustrated cases.

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.

Tc-99m stannous colloid-labeled leucocyte scintigraphy in the evaluation of brain abscess.

99mTc stannous colloid-labeled leukocyte scintigraphy was used to investigate brain abscesses in patients with underlying arteriovenous malformation or other brain abnormalities. 99mTc stannous colloid-labeled leukocytes are radiolabeled neutrophils and monocytes. The radiolabeled colloid is phagocytosed by the white cells. Six patients with underlying arteriovenous malformation (AVM) post embolisation with clinical diagnosis of brain abscess were studied. The 3 patients with positive 99mTc stannous colloid-labeled leukocyte scans were diagnosed as a cerebral abscess in all cases. One patient who had a negative 99mTc stannous colloid-labeled leukocyte scan did not have a brain abscess. Another with a negative scan had a pathologic diagnosis of chronic inflammation and foreign body reaction. The third with a negative scan was studied after treatment with antibiotic and debridement. In Summary 99mTc stannous colloid-labeled leukocyte scintigraphy is useful in conjungtion with CT scanning in investigating patients with brain abscess who have other underlying brain abnormality or who have an early brain abcess, or in the follow up of patients who have already received treatment in order to evaluate infection is still present and it is appropriate treatment.