Traumatic carotid-rosenthal fistula treated with Jostent Graftmaster

Abstract

Traumatic injuries of the carotid artery may result in severe morbidity and mortality. The most common location of carotid artery injury is the cavernous segment, which may result in fistulous connection to the cavernous sinus and ophthalmic veins, which in turn lead to pressure symptoms in the ipsilateral orbit. Unlike the commonly reported direct traumatic carotid-cavernous fistula, we describe an unusual case of a 38-year-old man presented with a traumatic brain injury led to a fistula connection between the cavernous carotid artery and the ipsilateral basal vein of Rosenthal, with eventual drainage to the straight and transverse sinuses. The basal vein of Rosenthal is usually formed from confluence of anterior and middle cerebral veins deep in the Sylvian fissure and drain the insular cortex and the cerebral peduncles to the vein of Galen. Immediate endovascular deployment of a covered stent in the cavernous carotid artery allowed sealing the laceration site. Three months follow up showed a non-focal neurological examination and healed carotid laceration over the covered stent. INTRODUCTIONBlunt craniocervical vascular injuries are uncommon with estimated incidence of 1.1%-2.7% in a screened blunt head trauma population [1] . The prevalence of carotid injury with skull base fracture is 2%, which appear more common in females [2] . Most commonly reported location of the fistulous connection is between the cavernous carotid artery (CCA) and the cavernous sinus resulting in direct and less commonly indirect carotid-cavernous fistulae [3] . The cavernous sinus drains anteriorly to the ophthalmic vein and thus, most of these fistulae result into pressure symptoms in the ipsilateral orbit. Though less frequently, injury to the CCA may lead to intracerebral and subarachnoid hemorrhages. Injury to the CCA CASE REPORT Traumatic carotid-rosenthal fistula treated with Jostent Graftmasterwith fistulous connection to deep cerebral vein is more complex and has not been reported. We present a case of traumatic laceration of the CCA with fistulous connection to the basal vein of Rosenthal following a traumatic brain injury with basilar skull fracture and traumatic subarachnoid hemorrhage. We discuss treatment options including a covered stent placement to seal the carotid laceration. CASE REPORTA 38-year-old man with a known history of epilepsy presented to the emergency department after falling off a motorized bicycle resulting in multiple facial and skull base fractures. On admission, he was awake and alert with initial Glasgow Coma Scale of 14 that rapidly decline to 4; he required sedation and emergent endotracheal intubation. Immediate cranial computed tomography showed multiple fractures in the face and skull base with Fisher grade IV subarachnoid hemorrhage and evidence of air at the skull base. Emergent 6-vessel cerebral angiogram revealed contrast extravasation at the cavernous segment of the left CCA ( Figure 1A and B). The blood leakage pointed medially and posteriorly with evidence of early venous fi...