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Right external carotid artery angiogram demonstrates multiple small feeding arteries to supply the indirect carotid cavernous fistula (single arrow). There is arterialization of the bilateral cavernous sinuses, circular sinus, and the left superior ophthalmic vein (double arrows). "Right" indicates the patient's right side.
Source publication
Carotid cavernous fistulae (CCF) are defined as abnormal connections between the carotid circulation and cavernous sinus. CCFs can be categorized as being direct or indirect. Direct CCFs are usually associated with trauma, whereas indirect CCFs are associated with revascularization following cavernous sinus thrombosis. We present a case of a 53-yea...
Context in source publication
Context 1
... patient was a 53-year-old male with a high-flow indirect carotid cavernous fistula with bilateral SOV and retrograde cortical vein drainage. An initial intracranial magnetic resonance angiogram (MRA) revealed flow-related arterial signals in the left more than right cavernous sinuses ( Figure 1). His clinical presentation included tinnitus, proptosis, conjunctivitis, and blurry vision. A physical exam showed elevated intraocular pressures bilaterally. Arterial input was from innumerable small branches of both external and internal carotid arteries (Figures 2-4). A recently attempted endovascular transvenous embolization was only partially successful with residual carotid cavernous fistula draining to the left SOV and multiple cortical veins ( Figure 5). On the initial embolization attempt, there was no communication between either inferior or superior petrosal or cavernous sinuses. The initial partial embolization required transvenous access through the right facial vein into the right SOV and across the circular sinus into the left cavernous sinus. As the left cavernous sinus had multiple septated compartments, only a portion of the left cavernous sinus could be accessed for embolization from the right transfacial venous approach. A subsequent encounter for transvenous embolization using a left orbital surgical cut-down approach to the SOV was planned to provide access to the cavernous ...
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Purpose
To determine the role of Contrast enhanced MRI (CEMRI) in the evaluation of Cavernous sinus thrombosis (CST).
Method
The study included 7 patients with an imaging diagnosis of cavernous sinus thrombosis. A retrospective analysis of Contrast enhanced MRI of 9 affected cavernous sinuses and a control group of 7 patients (14 cavernous sinuses...
Citations
... These 14 articles were included in our final analysis (Table 1). [16][17][18][19][20][21][22][23][24][25][26][27][28][29] Our review revealed oculoplastic surgery as the most commonly involved specialty during the procedure (5 of 14 studies; 35.7%). ...
... Management of CCFs often mandates close coordination between ophthalmology, neurosurgery, and interventional neuroradiology. [16][17][18][19][20][21][22][23][24][25][26][27][28][29] Endovascular intervention using transvenous embolization technique with detachable coils or liquid embolic agents has largely been accepted as the first-line treatment modality that has been proved to be safe and effective with high rates of complete obliteration and a concomitantly low complication rate. 7,10-13 With more operator experience and advances in neurointervention device technology, rates of complete obliteration have increased significantly, ranging from 70% to 90%, with the rate of complications reported as low as 3.6% of cases. ...
Background:
Failure to reach the cavernous sinus after multiple transvenous attempts, although rare, can be challenging for neurointerventionists. The authors sought to demonstrate technical considerations and nuances of the independent performance of a novel hybrid surgical and endovascular transpalpebral approach through the superior ophthalmic vein (SOV) for direct coil embolization of an indirect carotid cavernous fistula (CCF), and they review salient literature regarding the transpalpebral approach.
Observations:
An illustrative case, including patient history and presentation, was reviewed. PubMed, MEDLINE, and Embase databases were searched for articles published between January 1, 2000, and September 30, 2021, that reported ≥1 patient with a CCF treated endovascularly via the SOV approach. Data extracted included sample size, treatment modality, surgical technique, performing surgeon specialty, and procedure outcome. The authors' case illustration demonstrates the technique for the hybrid transpalpebral approach. For the review, 273 unique articles were identified; 14 containing 74 treated patients fulfilled the inclusion criteria. Oculoplastic surgery was the most commonly involved specialty (5 of 14 studies), followed by ophthalmology (3 of 14). Coiling alone was the treatment of choice in 12 studies, with adjunctive use of Onyx (Medtronic) in 2.
Lessons:
The authors' technical case description, video, illustrations, and review provide endovascular neurosurgeons with a systematic guide to conduct the procedure independently.
... If treatment is necessary, it usually blocks the blood flow through the embolization of the cavernous sinus via the femoral vein or prevents blood flow by slowing the flow of blood vessels and causing thrombus [5][6] . If pure, conventional vascular intervention is impossible due to malformations, deformation, or thrombosis of the petrosal vein or other alternative vascular pathways, embolization of the cavernous sinus through the direct superior ophthalmic vein may be attempted [7][8][9][10] . In the case of the superior ophthalmic vein, when the vessel is dilated, it is easy to secure and manipulate the blood vessel and to insert the catheter. ...
... Difficulties with the IPS approach have led many practitioners to consider direct access of an ophthalmic vein through surgical exposure. [15][16][17][18][19][20][21][22] This can mitigate difficulties with access found in transfacial access to the SOV, but catheterization remains challenging, and such an approach introduces a more morbid surgical wound into the procedure. 23 In this series, a direct access to the SOV was only required in 1 (0.4%) case. ...
BACKGROUND: Endovascular surgery is the first-line treatment for indirect cavernous carotid fistulae (CCFs). This study compares multiple treatment techniques. OBJECTIVE: To compare endovascular techniques for indirect CCF treatment. METHODS: Retrospective analysis was performed of prospectively maintained records at 4 centers, identifying patients undergoing indirect CCF embolization. Demographics, symptoms, and lesion characteristics were recorded. Medical records were reviewed for changes in symptoms, delayed complications, and angiographically proven recurrence. Univariate and multivariate analyses were performed to identify impacts of the above characteristics on outcomes. RESULTS: Sufficient records were available for 267 patients treated between January 1987 and December 2016. Obliteration was achieved in 86.5% patients, occurring in 86.9% of exclusively transvenous treatments and 79.5% of other treatments. Obliteration rates were highest following transvenous embolization using coils compared to all other materials (likelihood ratio [LR] 5.0, P = .024). Complications were less common with coil embolization compared to other materials (LR 0.070, P < .001). Embolization with liquid embolics resulted in higher complication rates (LR 10.2, P = .002), although risk was reduced when used in conjunction with coils. Angiographically confirmed recurrence was more common following embolization with polyvinyl alcohol (LR 9.9, P = .004) and when multiple embolic agents were used (LR 6.6, P = .018). Delayed development of symptoms following embolization was less common following embolization with coils (LR 0.20, P = .030) and more common following embolization with liquids (LR 6.5, P = .014). CONCLUSION: To treat indirect CCFs, transvenous coil embolization is the safest and most effective technique. Liquid embolics are less effective and have more complications and should be carefully considered only in extenuating circumstances.
... Difficulties with the IPS approach have led many practitioners to consider direct access of an ophthalmic vein through surgical exposure. [15][16][17][18][19][20][21][22] This can mitigate difficulties with access found in transfacial access to the SOV, but catheterization remains challenging, and such an approach introduces a more morbid surgical wound into the procedure. 23 In this series, a direct access to the SOV was only required in 1 (0.4%) case. ...
Background:
Endovascular surgery is the first-line treatment for indirect cavernous carotid fistulae (CCFs). This study compares multiple treatment techniques.
Objective:
To compare endovascular techniques for indirect CCF treatment.
Methods:
Retrospective analysis was performed of prospectively maintained records at 4 centers, identifying patients undergoing indirect CCF embolization. Demographics, symptoms, and lesion characteristics were recorded. Medical records were reviewed for changes in symptoms, delayed complications, and angiographically proven recurrence. Univariate and multivariate analyses were performed to identify impacts of the above characteristics on outcomes.
Results:
Sufficient records were available for 267 patients treated between January 1987 and December 2016. Obliteration was achieved in 86.5% patients, occurring in 86.9% of exclusively transvenous treatments and 79.5% of other treatments. Obliteration rates were highest following transvenous embolization using coils compared to all other materials (likelihood ratio [LR] 5.0, P = .024). Complications were less common with coil embolization compared to other materials (LR 0.070, P < .001). Embolization with liquid embolics resulted in higher complication rates (LR 10.2, P = .002), although risk was reduced when used in conjunction with coils. Angiographically confirmed recurrence was more common following embolization with polyvinyl alcohol (LR 9.9, P = .004) and when multiple embolic agents were used (LR 6.6, P = .018). Delayed development of symptoms following embolization was less common following embolization with coils (LR 0.20, P = .030) and more common following embolization with liquids (LR 6.5, P = .014).
Conclusion:
To treat indirect CCFs, transvenous coil embolization is the safest and most effective technique. Liquid embolics are less effective and have more complications and should be carefully considered only in extenuating circumstances.
Purpose
Cavernous sinus dural arterio-venous malformations (dAVF) represent a pathologic connection between branches of the internal and/or external carotid artery and the cavernous sinus. Standard endovascular approaches for dAVF treatment are transvenous embolization through the inferior petrosal sinus or the facial vein and transarterial embolization. These approaches are not always successful or feasible, and alternative techniques are required. Here, we present a case series of a minimally invasive transorbital approach with surgical exposure and catheterization of the superior ophthalmic vein for transvenous fistula coiling.
Methods
14 patients with dAVFs (Barrow Type B to D) that were treated at a tertiary care medical center over a period of 13 years were included in the study. Patients with persisting dAVF associated symptoms were selected for this approach when conventional endovascular interventions were not successful or not feasible. The surgical procedure was performed under general anaesthesia.
Results
A successful transorbital approach was performed in all 14 cases. In 12 of 14 patients a catheter assisted successful embolization of the fistula was performed using platinum coils with no relevant residual fistula flow. In two cases, a spontaneous thrombosis of the fistula during the surgical procedure required no further embolization. No postoperative therapy-associated complications were observed.
Conclusion
The described approach is an effective method to embolize dAVFs in selected cases when catheter assisted transvenous and/or transarterial embolization is not successful or not feasible. In this case series we demonstrate an excellent success rate with no therapy-associated major complications.
Purpose:
New therapies for melanoma have been associated with increasing survival expectations, as opposed to the dismal outcomes of only a decade ago. Using a prospective registry, we aimed to define current survival goals for melanoma patients with brain metastases (BM), based on state-of-the-art multimodality care.
Methods:
We reviewed 171 melanoma patients with BM receiving stereotactic radiosurgery (SRS) who were followed with point-of-care data collection between 2012 and 2020. Clinical, molecular and imaging data were collected, including systemic treatment and radiosurgical parameters.
Results:
Mean age was 63 ± 15 years, 39% were female and 29% had BRAF-mutated tumors. Median overall survival after radiosurgery was 15.7 months (95% Confidence Interval 11.4-27.7) and 25 months in patients managed since 2015. Thirty-two patients survived [Formula: see text] 5 years from their initial SRS. BRAF mutation-targeted therapies showed a survival advantage in comparison to chemotherapy (p = 0.009), but not to immunotherapy (p = 0.09). In a multivariable analysis, both immunotherapy and the number of metastases at 1st SRS were predictors of long-term survival ([Formula: see text] 5 years) from initial SRS (p = 0.023 and p = 0.018, respectively). Five patients (16%) of the long-term survivors required no active treatment for [Formula: see text] 5 years.
Conclusion:
Long-term survival in patients with melanoma BM is achievable in the current era of SRS combined with immunotherapies. For those alive [Formula: see text] 5 years after first SRS, 16% had been also off systemic or local brain therapy for over 5 years. Given late recurrences of melanoma, caution is warranted, however prolonged survival off active treatment in a subset of our patients raises the potential for cure.
Cerebrovascular injury is a potentially devastating outcome following craniofacial trauma. Interventional radiologists play an important role in detecting, grading, and treating the different types of vascular injury. Computed tomography angiography plays a significant role in the detection of these injuries. Carotid-cavernous fistulas, extra-axial hematomas, pseudoaneurysms, and arterial lacerations are rare vessel injuries resulting from craniofacial trauma. If left untreated, these injuries can lead to vessel rupture and hemorrhage into surrounding areas. Acute management of these vessel injuries includes early identification with angiography and treatment with endovascular embolization. Endovascular therapy resolves vessel abnormalities and reduces the risk of vessel rupture and associated complications.
