Endovascular therapy of carotid cavernous fistulas

The clinical manifestations of carotid cavernous fistulas, regardless of the type, depend on the pattern of venous drainage from the fistula. Venous drainage toward the orbit produces the usual syndrome of proptosis, chemosis, and arterialization of scleral veins. If the venous drainage is toward the brain, the signs and symptoms may not be as apparent, but the risk for catastrophic hemorrhage is much higher. Although many of these lesions may be managed in a conservative fashion, there are indications for urgent treatment to prevent a devastating hemorrhage or loss of vision. Direct carotid cavernous fistulas can usually be managed by transarterial embolization, most commonly with detachable balloons. The transvenous approach is most efficacious for treating indirect carotid cavernous fistulas.     

Spontaneous dural carotid cavernous sinus fistula presenting isolated ophthalmoplegia: evaluation with MR angiography

We describe three patients with spontaneous dural carotid cavernous sinus fistula presenting an isolated ophthalmoplegia where magnetic resonance angiography demonstrated abnormal flow-related enhancements in the cavernous sinus with extension into the inferior petrosal sinus. Magnetic resonance angiography is of value in evaluation of patients with isolated ophthalmoplegia.     

Fatal subarachnoid hemorrhage from an inflammatory cavernous carotid artery aneurysm: failure of conservative treatment after early diagnosis--case report

Inflammatory carotid artery aneurysm is a rare complication of acute paranasal sinusitis. A 50-year-old female presented with a ruptured giant carotid artery aneurysm secondary to infection of the sphenoid sinus and cavernous sinus. She had been healthy until 5 days before admission, when she developed orbital phlegmon and meningitis. She received antibiotic therapy for 10 days. Computed tomography (CT) of the brain 2 days after admission showed no abnormality. However, repeat CT on day 6 showed a round isodense mass in the suprasellar cistern suggesting a cerebral aneurysm. Twelve days after admission, she suffered a fatal subarachnoid hemorrhage. Cerebral angiography revealed a giant left cavernous carotid artery aneurysm with a very irregular shape. Autopsy found sphenoid sinusitis and osteomyelitis extending into the cavernous sinuses. Diagnosis of bacterial inflammatory aneurysms before rupture is very important. Appropriate surgical intervention should be considered if there is enlargement of the original aneurysm or appearance of a new aneurysm indicating a potentially dangerous situation.     

Orbital venous approach to the cavernous sinus: an analysis of the facial and orbital venous system

Carotid-cavernous fistulas are abnormal communications between the internal carotid artery and the cavernous sinus produced by a rupture of the wall of the carotid artery or one of its branches into the sinus. Extradural branches of the internal or external carotid arteries may communicate with the cavernous sinus, producing proptosis, progressive glaucoma, and ocular vascular engorgement. Various approaches to obliterate these fistulas have evolved, many of which carry high morbidity or are precluded by anatomical considerations. Analysis of the venous anatomy of the orbit and face, including human cadaver dissections, reveals a new and safe approach to the cavernous sinus, requiring microsurgical isolation and cannulation of the superior ophthalmic vein through an anterior orbital approach. Selective embolization of a carotid-cavernous fistula can be performed successfully through this route. We present pertinent anatomy and technical considerations and the successful clinical application of these principles. Surgeons familiar with craniofacial anatomy and microvascular techniques can apply these principles and play an active role in the treatment of these complex problems.     

Deflation of detachable balloons in the cavernous sinus by percutaneous puncture

The authors show that percutaneous puncture of balloons within the cavernous sinus is technically feasible and allows further access to the cavernous sinus after balloon detachment. Complete closure of a large carotid cavernous fistula was achieved in the 37-year-old trauma victim they treated using this technique.     

Traumatic carotid cavernous sinus fistula: serial angiographic studies from the day of trauma

BACKGROUND AND PURPOSE: The purpose of this study was to ascertain the early angiographic features characteristic of traumatic carotid cavernous sinus fistulas (CCFs). METHODS: Eight patients with severe craniofacial injuries underwent emergency diagnostic and therapeutic angiography for intractable oronasal bleeding, starting on an average of 6.7 hours after trauma. Carotid angiograms and the clinical manifestation of traumatic CCFs were then reviewed retrospectively to determine characteristic angiographic features. RESULTS: In four of the eight patients, no arteriovenous fistulas were found in the cavernous sinuses and symptomatic CCF did not occur during the follow-up period. In the remaining four patients, dural CCFs (Barrow type B) were observed, unilaterally in three patients and bilaterally in one. One of these four patients subsequently became symptomatic and required transarterial coil embolization. CONCLUSION: Traumatic dural CCFs are frequently observed in the early stage of severe craniofacial trauma, if investigated. Although their spontaneous disappearance is known, some of these do become symptomatic and need treatment.     

The petrolingual ligament: the anatomy and surgical exposure of the posterolateral landmark of the cavernous sinus

The petrolingual ligament is the posteroinferior attachment of the lateral wall of the cavernous sinus, where the internal carotid artery enters the cavernous sinus. The petrous segment of the internal carotid artery finishes and the cavernous segment begins at the superior margin of this ligament. The ligament is surgically important due to its identification as a landmark for dissection of the internal carotid artery during the approaches to posterolateral intracavernous and extracavernous lesions. It can be well exposed after mobilization of the gasserian ganglion, or after the trigeminal root and ganglion have been split along the junction of V2 and V3 (the transtrigeminal approach). The petrolingual ligament was studied in five cadaveric head specimens from ten sides. The size of the ligament was measured, and its anatomical, clinical and surgical importance is discussed.     

Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: technical case report

OBJECTIVE AND IMPORTANCE: The endovascular treatment of carotid-cavernous dural fistulae is becoming the prominent treatment modality for these lesions. The intractability of these lesions and their tendency to recur, especially after previous endovascular treatment sessions, exhausts the available routes and tends to present a difficulty in accessing the cavernous sinus. To avoid the risks associated with a direct surgical approach, an alternative, less invasive route to the cavernous sinus using a pretemporal extradural approach is combined with a direct endovascular approach. CLINICAL PRESENTATION: A 38-year-old woman presented with a history of right visual and ocular symptoms related to a Type D cavernous carotid dural fistula, which was fed by internal carotid and external carotid branches. The fistula was initially treated with embolization of the external carotid arterial supply. After a transient improvement, the patient's visual acuity worsened. A follow-up angiogram showed the major supply from the intracavernous internal carotid branches and draining through the inferior ophthalmic vein. The transvenous route was not accessible. An attempt to cannulate the intracavernous branches was not successful. The combined pretemporal and endovascular approach was then used. INTERVENTION: The pretemporal extradural region of the superior orbital fissure was exposed. Using microsurgical techniques and Doppler flow guidance, the anterior cavernous sinus was cannulated through the orbital venous drainage channels. Using intraoperative angiography, thrombogenic coils were deployed at the level of the fistula. Intraoperative angiography confirmed complete obliteration of the fistula. CONCLUSION: The combined pretemporal (extradural) and endovascular approach to the cavernous sinus is a less invasive alternative for the treatment of intractable carotid-cavernous dural fistulae.     

The suboccipital cavernous sinus

The authors studied the microsurgical anatomy of the suboccipital region, concentrating on the third segment (V3) of the vertebral artery (VA), which extends from the transverse foramen of the axis to the dural penetration of the VA, paying particular attention to its loops, branches, supporting fibrous rings, adjacent nerves, and surrounding venous structures. Ten cadaver heads (20 sides) were fixed in formalin, their blood vessels were perfused with colored silicone rubber, and they were dissected under magnification. The authors subdivided the V3 into two parts, the horizontal (V3h) and the vertical (V3v), and studied the anatomical structures topographically, from the superficial to the deep tissues. In two additional specimens, serial histological sections were acquired through the V3 and its encircling elements to elucidate their cross-sectional anatomy. Measurements of surgically and clinically important features were obtained with the aid of an operating microscope. This study reveals an astonishing anatomical resemblance between the suboccipital complex and the cavernous sinus, as follows: venous cushioning; anatomical properties of the V3 and those of the petrous-cavernous internal carotid artery (ICA), namely their loops, branches, supporting fibrous rings, and periarterial autonomic neural plexus; adjacent nerves; and skull base locations. Likewise, a review of the literature showed a related embryological development and functional and pathological features, as well as similar transitional patterns in the arterial walls of the V3 and the petrous-cavernous ICA. Hence, due to its similarity to the cavernous sinus, this suboccipital complex is here named the "suboccipital cavernous sinus." Its role in physiological and pathological conditions as they pertain to various clinical and surgical implications is also discussed.     

Meningeal architecture of the cavernous sinus: clinical and surgical implications

OBJECTIVE: The meningeal structure of the cavernous sinus (lateral sellar compartment) was anatomically and histologically studied. We discuss the clinical and surgical significance and present clinical examples of cranial base tumors. METHODS: Ten adult cadaveric heads were used for microsurgical dissection or histological studies. Specimens of the cavernous sinus were continuously sectioned in three dimensions and stained by Masson's trichrome method. The findings are anatomically discussed as they pertain to presented clinical cases. RESULTS: The cavernous sinus, located in an interdural space between periosteal and meningeal dura, is properly accessed by detachment of the periosteal bridge between the superior orbital fissure and the middle fossa. The lateral meningeal dura is dissected under minimal hemorrhage from the sinus, with a surgically important cleaving plane between the "deep layer," a semitransparent meningeal sheath with which the cranial nerves are covered and protected. It has various degrees of meningeal pockets, of which Meckel's cave is the largest example. Adventitia of the carotid artery in the sinus, uncovered with protective meninges, is considered to contact directly with tumors of the sinus origin. The meningeal wall of the cavernous sinus anatomically has three weak points as far as tumor invasion and extension are concerned: the venous plexus around the superior orbital fissure, the loose texture of the medial wall around the pituitary body, and dural pockets of the IIIrd and Vth cranial nerves. The dural wall is extremely thin or missing at those points. CONCLUSION: A surgical technique based on the meningeal anatomy is important for cavernous sinus surgery. The cavernous apex and Meckel's cave, which are spaces of convergence of cranial nerves, however, are weak points for surgical dissection. The presence or absence of tumor invasion into those areas may influence the microsurgical results.     

Appearance of a cavernous hemangioma in the cerebral cortex after a biopsy of a deeper lesion

Cavernous hemangiomas are vascular malformations that can occur throughout the central nervous system. In certain patients, multiple lesions are known to occur. We present a patient with multiple cavernous hemangiomas who had a computed tomography-guided biopsy of a deep parieto-occipital lesion through a burr hole. Several passes of a biopsy needle were used. During a 5-year interval, the patient developed a new lesion directly under the burr hole on the cortical surface. The new lesion appears to have occurred from the implantation and growth of a cavernous hemangioma secondary to the biopsy.     

CT angiography of the carotid artery

CT angiography shows promise as a noninvasive method to display carotid vascular pathology. This article discusses technique, stenosis measurements, pitfalls, strengths, and weaknesses of CT imaging of the carotid artery.     

Mycotic aneurysm of the external carotid artery

Mycotic aneurysms of the extracranial carotid arteries are extremely rare. A case is reported of a false aneurysm of the left external carotid artery. This developed secondary to cervical lymphadenitis which did not settle with high dose antibiotic therapy. The diagnosis was made on investigation with carotid doppler ultrasound and confirmed with computerized tomography. Digital subtraction angiography was performed to highlight the vascular anatomy. In addition percutaneous balloon catheter control of blood flow in the external carotid artery was used as an adjunct to surgical management.     

Concomitants of atherosclerotic carotid artery stenosis

To identify metabolic and other concomitants of a single important type of atherosclerotic cerebrovascular disease, 75 patients with angiographically and surgically proven internal carotid stenosis were compared with age and sex matched control subjects with respect to plasma cholesterol, triglycerides and glucose. They were also compared for blood pressure, cigarette smoking, evidence of ischemic heart disease, peripheral vascular disease and for a family history of these diseases. Patients with carotid stenosis had higher systolic and diastolic blood pressures and higher plasma cholesterol and triglyceride concentrations than the control groups. They had, as well, a far greater likelihood of being cigarette smokers and a greater likelihood of having diabetes mellitus and previous evidence of coronary and peripheral vascular disease. Patients with carotid stenosis were far more likely to have 2 or more of these common concomitants of atherosclerosis than were the control subjects. The data suggest that the precursors of carotid stenosis are similar to those of coronary atherosclerosis and raise the hope that modification of these factors may decrease the incidence of this highly prevalent form of cerebrovascular disease.     

Intraparenchymatous vascular tumors of the testicle: report of a new case of cavernous hemangioma

The occurrence of a vascular tumour at the intraparenchymatous testicular level is a fact little reported in the literature. Searching for such events, 19 cases were found all of which showed benign clinical behaviour. The most commonly seen histological pattern is cavernous haemangioma (11 patients). Mean age at presentation is 19 years old and the most usual pre-operative diagnosis, germinal cell neoplasia. Since there are no specific ultrasound patterns that may allow to differentiate benign from malignant masses, inguinal orchiectomy is the choice treatment in this type of lesions. Furthermore, the case of a 44-year old patient with hypoechogenic solid mass in left testis who consulted for sporadic episodes of long-standing scrotal pain is presented. After radical exeresis of the gonad, the histological analysis showed existence of testicular cavernous haemangioma.     

Angioplasty and stenting of the carotid artery

Percutaneous endovascular techniques are well established procedures in the management of peripheral vascular disease and visceral arterial stenosis. They are now being adapted for use in the carotid artery as well. 8 patients with 9 extracranial carotid artery stenoses were successfully treated by percutaneous angioplasty, following which in 4 of them 5 stents were inserted. The stenotic lesions were situated in the proximal internal carotid artery and in its bifurcation and also in the common carotid artery. The indications for angioplasty in these patients were the same as for surgery. There were no major complications. 1 patient had transient hemiparesis lasting a few hours, and another had bradycardia following balloon dilation in the region of the carotid body. Percutaneous endovascular treatment of carotid artery stenosis is becoming a safe, feasible alternative to surgery.     

Familial cerebral cavernous angiomatosis

Two patient with familial cavernous angiomatosis presenting with long lasting variable epilepsy with a poor therapeutic response and variable neurologic impairments are presented here. One of the numerous cavernous angiomas was resected in one case. This last patient remains asymptomatic. Familial cerebral cavernous angiomas are often numerous and disseminated in the brain, therefore clinical manifestations are very polymorphous. Moreover the course of these lesions is variable. Therefore MRI should be performed to every patient presenting with poorly understood neurological symptoms, focal or generalized epileptic seizures or absence in order to look for potentially imputable brain lesions. A reliable genetic marker might be helpful for diagnosis of this disease with a variable penetrance and autosomal dominant inheritance. Then a neurosurgical treatment should be carefully discussed if lesions are accessible and medications are poorly efficient with recurrent neurologic impairments or epilepsy.     

Avid uptake of technetium-99m-HMPAO by an intracranial plasmacytoma during carotid balloon test occlusion

A 56-yr-old woman was evaluated for removal of a tumor at the base of the skull. A test to determine the risk of carotid artery sacrifice was performed prior to surgery using carotid balloon occlusion of the left internal carotid artery and 99mTc-HMPAO perfusion scintigraphy during the occlusion. An unusual intense focus of increased uptake was seen at the site of the primary tumor in the left cavernous sinus. The tumor, found to be plasmacytoma at surgery, demonstrated only mild washout from 30 min to 2 hr after administration of 99mTc-HMPAO, with a tumor-to-cerebellum ratio of 1.6 and 1.5, respectively, and a tumor-to-contralateral cranial ratio of 2.5 and 2.4, respectively. Intracranial plasmacytoma shows good response to radiation therapy, and the differentiation of this tumor from other neoplasms is pertinent to the mode of treatment and surgical approach. Technetium-99m-HMPAO SPECT imaging may be a useful tool in distinguishing these tumors from other neoplasms at the base of the skull.     

Hepatic cavernous hemangioma: appearance on T2-weighted fast spin-echo MR imaging with and without fat suppression

OBJECTIVE: The goals of our study were to define the morphologic appearance of cavernous hemangioma of the liver on T2-weighted fast spin-echo MR imaging and to determine if the use of fat suppression may quantitatively and qualitatively modify the MR imaging appearance of cavernous hemangioma. SUBJECTS AND METHODS: Twenty-six patients with cavernous hemangiomas of the liver were prospectively studied with T2-weighted MR imaging with a fast spin-echo technique with and without fat suppression. Thirteen patients had known hemangiomas for more than 2 years, with no change in size or morphology during this period. The remaining 13 patients had diagnoses based on dynamic CT and sonography and an absence of change in the morphology and size of their lesions during follow-up of more than 6 months (range, 6-12 months) after the MR imaging studies. Values for signal intensity and contrast-to-noise (C/N) ratios in cavernous hemangiomas that were obtained with and without fat suppression were compared. Images were qualitatively analyzed separately at identical level and window settings by two interpreters for morphologic features of cavernous hemangiomas. RESULTS: No significant difference was found between signal intensity values obtained using the fat-suppressed fast spin-echo MR imaging technique (5.62 +/- 1.14 [SD]) and those obtained without fat suppression (5.51 +/- 1.23). Values for C/N ratios obtained with the fat-suppressed fast spin-echo MR imaging technique (20.13 +/- 7.63) were significantly superior to those obtained without fat suppression (16.59 +/- 5.31) (p < .001). On T2-weighted fast spin-echo MR imaging without fat suppression, 100% of cavernous hemangiomas were hyperintense relative to the spleen, 90% had well-defined and sharp margins, 55% were isointense to CSF, and 76% were homogeneous. Without fat suppression, 34% of cavernous hemangiomas showed the combination of isointensity to CSF, well-defined margins, and homogeneity. On T2-weighted fast spin-echo MR imaging with fat suppression, all cavernous hemangiomas showed this same combination of features. CONCLUSION: Seventy-six percent of hepatic cavernous hemangiomas were homogeneous on T2-weighted fast spin-echo MR imaging, and 55% were isointense to CSF. However, only 34% of hepatic cavernous hemangiomas showed typical features. Although fat suppression significantly increased the C/N ratio of cavernous hemangiomas of the liver, fat suppression did not affect their morphologic appearance on T2-weighted fast spin-echo MR imaging.     

Internal carotid artery agenesis and multiple aneurysms in the posterior communicating artery

Internal carotid artery agenesia is a rare anomaly of the embryonic development. We present a case with this anomaly and a vascular feeding of this territory out of the contralateral carotid system and the posterior vascular system. There were multiple aneurysms in the right posterior communicating artery, never described before in association with carotid agenesia, that are similar to the angiographic image of the fibromuscular dysplasia ("atypical" pattern). We review and discuss the embryonic development of this anomaly and its relationship with the hemodynamic stress and aneurysm formation.