UNASSIGNED: A carotid-cavernous sinus fistula (CCF) is an abnormal communication between the internal carotid artery and/or the external carotid artery and the cavernous sinus. There is a paucity of information on the ophthalmic outcomes of endovascular treatment for CCF in the Philippines.
UNASSIGNED: This study aimed to describe the clinical experience of CCF in our institution in order to further our understanding of the disease. This study described the demographic profile, risk factors, and clinical features of patients with CCF, and compared the data of patients according to the type of CCF. The study discussed the changes in clinical features over time in CCF patients who chose not to undergo endovascular treatment. The study also discussed the clinical outcomes of CCF patients who underwent endovascular treatment and compared the clinical outcomes to CCF patients who did not undergo endovascular treatment.
UNASSIGNED: A retrospective cohort study design was performed using a medical record review of patients clinically diagnosed with CCF from January 2011 to June 2019.
UNASSIGNED: One hundred twenty medical records of patients diagnosed with CCF were included. Based on angiographic findings, patients were grouped according to type of CCF, with 86 patients in Group 1 or Direct CCF, 23 patients in Group 2 or Indirect CCF, and 11 patients in Group 3 or Mixed type of CCF. The patients were also grouped according to treatment, with 109 patients in Group A, or patients who did not undergo endovascular treatment, and 11 patients in Group B, or patients who underwent endovascular treatment. There was a male predominance in CCF, most occurring in the age range of 26 to 35 years. Risk factors for CCF were trauma and hypertension. Clinical features included the presence of blurring of vision, proptosis, corkscrewing of conjunctival vessels, extraocular movement limitation, diplopia, audible bruit, elevated intraocular pressure, and pulsation. Findings on Computed Tomography scan included dilated superior ophthalmic vein, proptosis, and enlarged extraocular muscles. Direct CCF (Group 1) occurred mostly in males, with mean age of 39.1 years, and with trauma as the major risk factor. Indirect CCF (Group 2) occurred mostly in females, with mean age of 52.1 years, and with hypertension as the major risk factor. Regardless of the type of CCF, patients who did not undergo endovascular treatment can exhibit spontaneous improvement or worsening of clinical features. Patients who underwent endovascular treatment generally had favorable clinical outcomes, manifesting as either improvement or no worsening of features. There were minimal ophthalmic complications associated with treatment.
UNASSIGNED: Endovascular treatment is safe and effective in the improvement of visual acuity, corkscrewing of conjunctival vessels, amount of proptosis, extraocular movement limitation, diplopia, and presence of audible bruit.

BACKGROUND: The goal of therapy for traumatic carotid-cavernous fistula (TCCF) is the elimination of fistula while maintaining patency of the parent artery. The treatment for TCCF has evolved from surgery to endovascular management using detachable balloons, coils, liquid embolic agents, covered stents, or flow-diverter stent through arterial or venous approaches. Despite the withdrawal of detachable balloons from the market in the United States since 2004, transarterial embolization with detachable balloons has currently remained the best initial treatment for TCCF in several countries. However, the pseudoaneurysm formation following transarterial detachable balloon embolization has rarely been observed in long-term follow-up.
OBJECTIVE: To determine the occurrence and long-term follow-up of pseudoaneurysm after transarterial detachable balloon for TCCF.
METHODS: Between January 2009 and December 2019, 79 patients diagnosed with TCCF were treated using detachable latex balloons (GOLDBAL) of four sizes. Pseudoaneurysm sizes were stratified into five grades for analysis. Initial and follow-up assessments involved computed tomography angiography at 1 month, 6 month, 1 year, and longer intervals for significant cases. Clinical follow-ups occurred semi-annually for 2 years, then annually. Factors analyzed included sex, age, fistula size and location, and balloon size.
RESULTS: In our cohort of 79 patients treated for TCCF, pseudoaneurysms formed in 67.1%, with classifications ranging from grade 0 to grade 3; no grade 4 or giant pseudoaneurysms were observed. The majority of pseudoaneurysms did not progress in size, and some regressed spontaneously. Calcifications developed in most large pseudoaneurysms over 5-10 years. Parent artery occlusion occurred in 7.6% and recurrent fistulas in 16.5%. The primary risk factors for pseudoaneurysm formation were identified as the use of specific balloon sizes, with balloon SP and No. 6 significantly associated with its occurrence (P = 0.005 and P = 0.002, respectively), whereas sex, age, fistula size, location, and the number of balloons used were not significant predictors.
CONCLUSIONS: Pseudoaneurysm formation following detachable balloon embolization for TCCF is common, primarily influenced by the size of the balloon used. Despite this, all patients with pseudoaneurysms remained asymptomatic during long-term follow-up.

Herein, we report a unique case of nontraumatic direct carotid-cavernous fistula presenting with intracerebral hemorrhage without any ocular symptoms. A 90-year-old woman was found unconscious and vomiting due to a subcortical hemorrhage in the temporal lobe. Magnetic resonance angiography revealed a direct carotid-cavernous fistula of Barrow type A. Extensive cortical venous reflux from the superficial middle cerebral vein was observed and identified as a probable contributor to the cerebral hemorrhage. We performed successful embolization using combined transarterial and transvenous approaches. We first occluded the dangerous venous drainage via the transvenous approach, followed by selective occlusion of the direct carotid-cavernous fistula via the transarterial approach. This strategy provided that the dangerous venous drainage was completely occluded first in case complete obliteration could not be achieved with the transarterial approach.

BACKGROUND: Vascular Ehlers-Danlos syndrome (vEDS) because of COL3A1 mutations is a rare inherited collagen vascular disease associated with spontaneous arterial dissections, aneurysms, vessel rupture, and organ rupture. A direct carotid-cavernous fistula (CCF) is the most common central nervous system vascular anomaly in vEDS; however, its treatment is challenging due to extremely fragile arteries and veins.
METHODS: A 22-year-old woman presented with pulsatile tinnitus and mild diplopia. CCF formation without trauma, cervical dissecting aneurysms, thin skin, and multiple ligament tears, as well as a genetic analysis, led to a diagnosis of vEDS. To minimize the risk of vascular injury in the thoracoperitoneal cavity, the internal jugular vein was directly punctured and the CCF was embolized transvenously using the triple-overlay road-mapping technique without arterial monitoring. The CCF was completely occluded, and the patient showed an excellent clinical course without neurological or vascular complications.
CONCLUSIONS: Physicians and neurosurgeons should consider vEDS when treating younger patients with spontaneous CCF without trauma and investigate the possibility of genetic abnormalities and systemic vascular pathology. Transvenous embolization of a CCF through the transjugular route using the triple-overlay road-mapping technique can minimize the risk of vascular injury in a patient with vEDS.

BACKGROUND: Direct carotid-cavernous fistulas (dCCFs) are often treated endovascularly. However, because the dCCF is usually a high-flow shunt, it is often difficult to obtain an accurate vascular structure using conventional digital subtraction angiography (DSA). Here, the authors report a case of successfully treated dCCF using three-dimensional (3D) fused DSA images.
METHODS: The patient presented with tinnitus, followed by oculomotor palsy, prompting magnetic resonance imaging that indicated a dural arteriovenous fistula of the cavernous sinus. DSA was performed before treatment, and a diagnosis of dCCF due to a ruptured aneurysm was made. In this case, the 3D fused simulation images enabled the authors to obtain an accurate vascular structure, resulting in successful coil embolization.
CONCLUSIONS: Three-dimensional fusion images from DSA provide detailed anatomical information and are useful for treating high-flow dCCFs.

BACKGROUND: Endovascular treatment is the mainstay of treatment for carotid-cavernous fistulas, but endovascular approaches vary widely. The authors report a rare case of a direct carotid-cavernous fistula with cranial nerve symptoms caused by rupture of a giant aneurysm in which selective transvenous embolization via the pterygoid plexus was performed.
METHODS: An 81-year-old man presented with headache and various progressive cranial nerve symptoms due to a direct carotid-cavernous fistula caused by a ruptured giant aneurysm. All the draining veins visualized on preoperative examination immediately before the treatment were occluded except for the pterygoid plexus. Therefore, the authors chose the dilated pterygoid plexus to approach the shunted pouch at the cavernous sinus and achieve shunt obliteration by selective embolization with coils and n-butyl cyanoacrylate.
CONCLUSIONS: Careful study of the three-dimensional rotational images in the preoperative examination is important when considering the various approaches to surgery. The pterygoid plexus can be an effective venous approach route to reach the cavernous sinus area.

Rapid advances in emergent mechanical thrombectomy have resulted in a higher occurrence of arterial perforations during neurointerventions. Here, we report a case of internal carotid artery (ICA) perforation during mechanical thrombectomy in a 78-year-old man with a left middle cerebral artery occlusion. The ICA was perforated by a microcatheter during thrombectomy, forming a direct carotid-cavernous fistula. A two-stage drainer occlusion was conducted because of cortical venous reflex aggravation and ocular symptoms. Here, we report the perforation details and treatment, adding to evidence that ICA perforation with the microcatheter body is a concern during mechanical thrombectomy.

UNASSIGNED: With the evolution of the endovascular devices, the management of endovascular interventions has become the current standard therapy for traumatic carotid-cavernous fistula (TCCF). However, only endovascular treatment may not be feasible in some patients with atypical TCCF.
UNASSIGNED: We described three complex TCCFs that could not be managed by conventional endovascular methods. The first patient had recurrent TCCF previously treated by muscle embolization and ligation of affected carotid arteries 23 years ago. Another two patients had TCCFs association with large pseudoaneurysm within the sphenoid sinus. In each patient, the fistula was successfully closed by trapping procedure using a combination of endovascular and surgical treatment.
UNASSIGNED: To reduce costs of treatment, trapping operation by combining surgical and endovascular treatment may be considered as an alternative option for complex TCCF which has some features including chronic stage, preexisting carotid artery ligation, or association with large venous pouch of the cavernous sinus or sphenoid sinus pseudoaneurysm.

UNASSIGNED: Revascularization of the occluded internal carotid artery (ICA) through the vasa vasorum is exceedingly rare. Several previous studies hypothesized that the expansion of the vasa vasorum is associated with neovascularization related to the progression of atherosclerosis or plaque. The occurrence of reconstitution of the ICA through the vasa vasorum in traumatic carotid-cavernous fistula (TCCF) has rarely been reported.
UNASSIGNED: We described an extremely rare case of a 64-year-old woman who developed reconstitution of the occluded ICA through hypertrophied vasa vasorum supplying recurrent TCCF previously treated by ligation of the internal and external carotid arteries. Usual endovascular treatment may be challenging for this patient due to inaccessible route from the affected ICA through multiple small vessels. The patient was successfully treated with trapping procedure and obliteration the fistula using combined surgical and endovascular treatment.
UNASSIGNED: We speculated that the hypertrophied vasa vasorum in TCCF may cause by a sequela of previous arterial injury, spontaneous recanalization of the occluded artery by the formation of vasa vasorum, and/or hypertrophy of the vasa vasorum due to the high flow of the fistula.

Direct carotid-cavernous fistulas (DCCF) develop due to breach in the integrity of the wall of the internal carotid artery, and its localization can sometimes be difficult due to rapid high flow shunts. We hypothesized that 3D rotational angiography could locate the fistula site accurately, where an interrupted rim of the carotid wall would be silhouetted against opacified vascular structures. This finding was described as a broken-rim sign, and in this study, we assessed the utility of this sign in the localization of the shunt point of DCCF.
Retrospective analysis of 15 cases of DCCF was performed, and the rent was characterized based on the broken-rim sign. Two observers independently evaluated the results and compared them against the intraoperative observations.
The broken-rim sign was identified and correlated with the actual fistula site in 86.6% and 100% of patients by observers 1 and 2, respectively. The inter-rater agreement was 0.87 (P < 0.001). Misinterpretation was made in 2 patients by 1 observer, due to poor contrast opacification of the vascular structures secondary to very rapid shunting and mild movement artifacts.
Our study highlights the role of 3D rotational angiogram and analysis of the carotid wall in the localization of the shunt site in DCCF. The broken-rim sign accurately points to the location of the fistula.