Spontaneous Resolution Of An Aggressive Direct Carotid Cavernous Fistula Following Partial Transvenous Embolization Treatment: A Case Report And Review Of Literatures
Liao, W. J., Hsiao, C. Y., Chen, C. H., Tseng, Y. Y., & Yang, T. C. (2024). Spontaneous Resolution of an Aggressive Direct Carotid Cavernous Fistula Following Partial Transvenous Embolization Treatment: A Case Report and Review of Literatures. Medicina (Kaunas, Lithuania), 60(12), 2011. https://doi.org/10.3390/medicina60122011
View Original Source →Abstract
Traumatic direct type carotid cavernous fistula (CCF) is an acquired arteriovenous shunt between the carotid artery and the cavernous sinus post severe craniofacial trauma or iatrogenic injury. We reported a 46-year-old woman who had developed a traumatic direct type CCF after severe head trauma with a skull base fracture and brain contusion hemorrhage. The clinical manifestations of the patient included pulsatile exophthalmos, proptosis, bruits, chemosis, and a decline in consciousness. Magnetic resonance imaging (MRI) revealed engorgement of the right superior ophthalmic vein (SOV), perifocal cerebral edema in the right frontal–temporal cortex, right basal ganglia, and brain stem. Digital subtraction angiography (DSA) disclosed a direct type high-flow CCF with an aggressive cortical venous reflux drainage pattern, which was attributed to Barrow type A and Thomas classification type 5. After partial treatment by transvenous coil embolization for the CCF, the residual high-flow fistula with aggressive venous drainage had an unusual rapid spontaneous resolution in a brief period. Therefore, it is strongly recommended to meticulously monitor the clinical conditions of patients and perform brain MRI and DSA at short intervals to determine the treatment strategy for residual CCF after partial endovascular treatment.
Case Details
Disease Location
Brain (carotid-cavernous fistula)
Personal Characteristics
46-year-old woman, medically controlled hyperthyroidism
Clinical Characteristics
The patient was involved in a motor vehicle accident. The accident led to poor consciousness with glasgow coma scale (gcs) level at e4v1m4, nasal bleeding, and left otorrhea in the patient. A brain CT scan showed a small subdural hematoma over the right temporal lobe, right sylvian subarachnoid hemorrhage, and a right sellar floor fracture with sphenoid sinus hematoma upon arrival at the emergency room. The patient underwent right intracranial pressure monitor insertion for further monitoring and intensive care. She complained of a progressive right eye floater and flash 4 weeks later. Initial examination revealed right eye proptosis and conjunctival vessels engorgement, without chemosis, or tinnitus in the right ear. Rapidly progressive severe right eye exophthalmos, audible bruits, and chemosis developed within several days, highly suggesting right carotid-cavernous fistula. Brain MRI disclosed enforcement of the right sov and swelling of right orbital cavity. Digital subtraction angiography (dsa) was performed to confirm a dircet type high-flow of the right-side ica with reflux flow into the right sov and inferior ophthalmic vein (iov), the right superficial middle cerebral vein (smcv), the right superior petrosal sinus (sps), and the right inferior petrosal sinus (ips). The ccf was classified as barrow type a, thomas type 5. 3 days after dsa, transvenous endovascular embolization was performed. 28 guglielmi detachable coils (gdcs) were deployed into the ccf. However, there were still two fistulous points in the posterior part of the ccf showing severe arteriovenous shunts. The first was located at the right sphenoparietal sinus, daining into the right smcv. The second was at the right sps, wich caused severe cortal vein reflux (cvr).
Remission Characteristics
Brain MRI was followed up 3 dyas after endovascular treatment, which disclosed significantly decreased engorgement of the right sov and less perifocal edema in the right corpus striatum, midbrain, and pons. Dsa one month after tve, revealed that the residual ccf had spontaneously resolved without additional cortical reflux.
Treatment & Mechanisms
Proposed Remission Mechanisms
Thrombogenic properties of the contrast material of angiography probably induced spontaneous closure of the ccf
Clinical Treatment
Right intracranial pressure monitor insertion transvenous endovascular embolization
Non-Clinical Treatment
None reported