Purpose To report a rare case of spontaneous rupture of dysplastic trigeminal artery in the cavernous sinus, imaging findings and technical considerations for treatment with vessel preservation.
Case report A 47-years-old female presented to the emergency department with acute onset of left eye pain, redness, elevated intra-ocular pressure and left third nerve palsy.
Imaging findings CT angiography obtained at admission showed a dilated left cavernous sinus and a suspicion that there may be ipsilateral PTA. Digital subtraction angiogram (DSA) of the left internal carotid artery (ICA) demonstrated a very high flow carotid-cavernous fistula but the exact location of the tear was impossible to find on anterior circulation injection. An analysis of left vertebral injection, 3D-DSA and DynaCTTM demonstrated and mapped the location of the tear in proximal PTA. Vessel preservation was considered necessary since the left anterior inferior cerebellar artery arose from the PTA. Dual catheter access was obtained (left ICA and left vertebral) and the fistula catheterized from the basilar artery aspect of the PTA. Additional micro-catheter was placed across from left ICA into PTA across the tear in case a stent would be necessary to reconstruct the PTA. Complete coil occlusion of the fistula could be accomplished and stent was not required. The patient recovered fully from this fistula and 3rd nerve function was normal at 2-weeks follow-up.
Summary Persistent trigeminal artery is an anatomic variant seen in 0.1%–0.6% of cerebral DSAs. Although a handful of cases of PTA related carotid-cavernous fistula are reported in the literature, a determination that the tear was spontaneous and not related to underlying aneurysm is difficult or impossible. Our case demonstrates the utility of careful imaging in the angiography suite with the inclusion of DynaCTTM and simultaneous dual catheter (ICA and Vertebral) 3D imaging for evaluation. A well-planned endovascular approach is key when preservation of the parent vessels with closure of the fistula is the goal.
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