Diagnosis and management of trigemino-cavernous fistulas: case reports and review of the literature

Abstract

Although usually asymptomatic, a persistent trigeminal artery (PTA) can rarely be associated with a direct fistula to the cavernous sinus (ie, trigemino-cavernous fistula). We present three patients with trigemino-cavernous fistulas; two were subsequently treated using modern endovascular techniques while the third initially declined therapy. We then review the literature of reported cases of this unusual entity. The aberrant anatomy associated with a PTA presents unique challenges to the management of these lesions, and must be well delineated prior to treatment. Finally, conservative management of trigemino-cavernous fistulas, either de novo or recurrent, may be considered if they demonstrate no evidence of cortical venous reflux and patient symptoms are tolerable.

Persistent Trigeminal Artery - Anatomical Features and Clinical Significance

“…The relationship between PTA and trigeminal cavernous fistula or carotid-cavernous fistula was extensively described by Chen, Miller, Asai, Kim, Jin, Hurst, Ali et al [12,29,30,31,32,33,34]. They may develop either spontaneously or after a traumatic event, presenting most commonly with ocular symptoms [1,3].…”

“…In most cases described in the literature, the PTA was not presented with clinical symptoms. Although usually asymptomatic, PTAs are known to be associated with a wide range of pathology including: ischemic cerebrovascular accidents in the posterior brainstem and occipital area [6,13,15,16,17,1,19,20,21], trigeminal neuralgia [13,15,22,23,24,25,26], cranial nerve palsy [6,22], hyperprolactinemia and other pituitary disorders [27,28], carotid cavernous fistulas [12,29,30,31,32,33,34], aneurysms [1,2,5,15,35,36,37], vascular steal [1,3], arteriovenous malformations [22], intrasellar chordoma [38], craniopharyngioma [39], tinnitus [40], basilar artery hypoplasia [15,41].…”

Clinical Importance of the Persistent Primitive Trigeminal Artery in Vascular Lesions and Its Role in Endovascular Treatment

“…EVT can bring a good prognosis. In Miller et al's ( 46 ) review, overall, the rate of neurological deficit following EVT of a TCF was only 7%, and there was no mortality. Currently, EVT can be the first-line option for TCFs, including transarterial, transvenous, and combined transarterial and transvenous packing of the CS with coils or intra-aneurysmal coiling ( 47 – 49 ).…”

Endovascular electrothrombosis treatment for carotid cavernous fistula caused by ruptured primitive trigeminal artery aneurysm: a case report and literature review

“…While Enomoto and colleagues previously achieved success in treating several cases through ICA ligation [8] , such an approach is heavily contingent upon the Circle of Willis' compensatory capabilities and may elevate the risk of ow-related IAs over time. Consequently, in light of considerable innovations in interventional methodologies since the 1990s, endovascular therapy has emerged as the favored modality for managing PPTA aneurysms [19] . This paradigm incorporates procedures like balloon occlusion, coiling, and the synergistic application of coils with Onyx embolization.…”