Case 5:Carotid-Cavernous Fistula Accompanying With Aneurysms: A Treat For The Trick


1: Can Tho University of Medicine and Pharmacy VIETNAM.


2: Medical University of Ho Chi Minh City VIETNAM



Our patient was an 18 year old gentleman who had a history of motor vehicle accident 1 month ago. He sustained right maxillary bone fracture upon the injury. Few days ago, he presented to the University Medical Center with the right eye proptosis and bruit on the right frontal region. The clinical symptoms were highly suggestive of direct traumatic carotico-cavernous fistula (CCF).


Angiogram was perform and showed a direct carotico-cavernous fistula on the right side. The right middle cerebral artery (MCA) was demonstrated angiographically but the right anterior cerebral artery (ACA) was not opacified via the right internal carotid artery (ICA) run. The CCF showed high flow drainage to the cavernous sinus, petrosal sinus and right ophthalmic veins, but there was no cortical vein reflux. In the right ICA run, beside the presence of CCF, there were also two aneurysms in the distal portion of this parent ICA.


The left ICA run showed normal vasculature of the left ACA and left MCA. There was opacification of the right MCA via anterior communicating artery with normal configuration of the A1 segment of the right ACA. Likewise, the two aneurysms were depicted below the right MCA and ACA origins.


Initially, the patient was planned for the fistula embolization. However, we reckoned that if we just simply do the right CCF occlusion using detachable balloon and tried to preserve the right ICA, the re-vascularized flow from the right ICA would rupture the two aneurysms. This condition necessitated another safer treatment strategy.


In the right angiographic vertebral run, the aneurysms were observed just above the origin of the right posterior communicating artery (Pcom). There was only minimal supply from the right Pcom to the right MCA. These overall findings could make possible to save the patient from the fistula with occlusion of the right ICA till the distal portion which was below the right ACA-MCA bifurcation.


The balloon test was performed using 6F Corel balloon-carrying guider. The test showed quite good supply to the right MCA and the patient had no symptoms during occlusion. There were also collaterals to the right ophthalmic artery from the right temporal artery.


We decided to proceed with occlusion of the fistulous portion of the right ICA as being discussed. An 8F Corel balloon-carrying guider was exchanged with the inflated balloon within the cervical right ICA. Microcatheter Echelon  1.7F and Transcend 008” microguide wire were used to cannulate the ICA crossing the fistula and the aneurysmal portion. Totally 3 coils of 3mmx8mm were detached at the distal right ICA down to the fistulous portion. The right ICA and fistula occlusion were enforced by 2 balloons GoldBal2 at the petrous and cervical portions. The procedure was completed with occlusion of the right posterior communicating artery using a 2mmx8mm coil. Check run from the left ICA showed good flow to the right MCA without residual fistula.



Carotid-cavernous fistula concomitant with internal carotid aneurysms are uncommon. The repair of the fistula with attempt to preserve the ICA may carry a risk of aneurysm rupture because of the increased arterial pressure after flow correction. The good therapeutic option for this condition could be sacrifice of the parent vessels which can cover both the fistulous and the aneurysmal ICA portions.





Figure1: Diagnostic angiogram demonstrated right carotico-cavernous fistula with presence of aneurysms (arrow). 1a: image from the right ICA angiogram. 1b: image from the right vertebral artery angiogram.



Figure2: Post-embolization images with total occlusion of the right CCF. 1a: image from the left ICA angiogram with good flow to the right MCA. No evidence of residual fistula. 1b: image from the right vertebral artery angiogram (unsubstract). Balloon (arrows) were used for occlusion of the right ICA.