Traumatic Carotid Cavernous Fistula Concomitant with Pseudoaneurysm in the Sphenoid Sinus

Abstract

<jats:p> This study was designed to elucidate the generating mechanism, diagnosis and treatment of traumatic carotid cavernous fistula (tCCF) concomitant with pseudoaneurysm in the sphenoid sinus. Six cases of tCCF concomitant with pseudoaneurysm in the sphenoid sinus were analyzed in this study. Clinical history, neurological examination, CT and MRI scans, pre- and postembolization cerebral angiograms and follow-up data were included. </jats:p><jats:p> All patients presented with massive epistaxis and symptoms of tCCF. The pseudoaneurysms and fistulas were occluded with detachable balloons, and preservation of the parent artery in two cases. One patient also had indirect carotid cavernous fistula (CCF) on the contralateral side embolized by transfacial vein approach with microcoils. Complete symptom resolution was achieved in all cases, without procedure related complications. During the follow-up period all patients returned to work. </jats:p><jats:p> Falling from a high speed motorcycle without wearing a helmet may be one of the main causes of this disease. The site of impact during the accident mostly localizes in the frontal and lateral of the orbit. Intracavernous sinus hypertension of tCCF combining with fracture of the lateral wall of the sphenoid may lead to the formation of a pseudoaneurysm in the sphenoid sinus. MRI scan is very helpful in the diagnosis of this disease before the patient receives angiography. Detachable balloon occlusion of the pseudoaneurysm and fistula is a safe and efficient treatment. </jats:p>

Carotid-cavernous fistulas

“…Patients presenting with a failure of CCF closure after compression therapy should be considered for alternative treatment strategies. 12,30 It is worth noting that in our experience, conservative management of CCFs has generally been ineffective.…”

Comparison between different modalities of Endovascular treatment in Carotid Cavernous Fistula (CCF) and its short term outcome – Our Experience

“…In contrast to NBCA Ethylene-vinyl alcohol copolymer (Onyx) is a nonadhesive liquid that allows a longer injection time and rates and can be used safely and showed excellent penetration in the different compartments of the cavernous sinus allowing longer duration and controlled injection. [15][16][17][18][19][20] In our study we do not used Onyx in any case. In indirect (dural) CCF the goal of treatment is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus.…”

“…6,13 Less common presentations include intracerebral or subarachnoid hemorrhage in 5% of patients. 13,16 Urgent treatment is usually needed for direct and high flow fistulas in which endovascular embolization is mostly applied. Indirect, slow flow CCFs usually close spontaneously without treatment.…”

Trauma of the midface

“…In case of fractures reaching the canal of the carotid artery there is always the risk of developing a carotid cavernous fistula [ 222 ].…”