Background Direct carotid-cavernous sinus fistulas (dCCFs) are high-flow arteriovenous shunts between the internal carotid artery and the cavernous sinus. These lesions are often the sequela of trauma but can also arise spontaneously following a ruptured cavernous carotid artery aneurysm. Traditionally, endovascular treatment options for dCCFs included the use of detachable balloons or coils utilizing a transarterial, transvenous, or combined approach. More recently, we have utilized flow-diverting stents such as the Pipeline Embolization Device (PED) and judicious use of liquid embolic agents such as Onyx to achieve safe and effective occlusion of dCCFs.
Methods We describe our recent experience treating 6 consecutive patients with dCCFs utilizing the PED as the upfront treatment modality.
Results Six patients (4 males, 2 females, ages 14–75 y) with dCCFs were treated with the PED at our institution between 12/2011 and 9/2016. Three presented after head/facial trauma and 3 presented with spontaneous symptom onset. Two of these latter 3 patients had a known cavernous carotid artery aneurysm. One patient presented acutely with severe head and face trauma and a GCS of 8. Of the remaining 5 patients, all presented with ipsilateral chemosis and proptosis; 3 presented with vision impairment; 3 with ipsilateral abducens palsy; 1 with ipsilateral V1-distribution numbness. All 6 patients underwent embolization including placement of the PED. Five were treated with a combination of transvenous and transarterial approaches, including transvenous Onyx infusion in the cavernous sinus in 2 challenging cases. For the five patients treated with both the PED and transvenous techniques, the PED facilitated the use of transvenous coiling and Onyx administration by both altering the flow dynamics through the fistula and providing protection of the parent artery. Indeed, a transarterial balloon was utilized for additional parent vessel protection during transvenous treatment in only 3 of these patients. Four of the 6 patients exhibited complete angiographic resolution of their fistula immediately following treatment. Interestingly, the 2 patients with incomplete obliteration of their fistula at time of treatment were found to have complete resolution of their fistulas on follow-up angiograms, suggesting that the PED-induced alteration in flow promoted thrombosis of the fistula. Therefore, 100% of patients in this series had complete obliteration of their fistula following treatment. Longitudinal follow-up is available for 5 of these patients. On last angiographic follow-up (median 40 months), 100% had continued complete obliteration of their fistula. All patients had resolution of their symptoms following treatment. One patient suffered a basal ganglia stroke following treatment without permanent neurologic consequence.
Conclusions We believe that the upfront use of the PED for the treatment of dCCFs is safe and efficacious for these lesions and facilitates parent vessel protection during transvenous coiling and/or onyx infusion. Further, the flow alterations induced by the PED may promote thrombosis of incompletely occluded fistulas. To our knowledge, this is the first reported series of dCCFs treated utilizing the PED as the initial treatment strategy.
Disclosures J. Baranoski: None. A. Ducruet: None. C. Przybylowski: None. R. Almefty: None. D. Ding: None. F. Albuquerque: None.
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