Treatment of carotid-cavernous fistulas by cavernous sinus occlusion

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✓ The author reports the occlusion of 33 carotid-cavernous fistulas in 31 patients using thrombogenic techniques. In one patient the carotid artery had been occluded previously, in one it was occluded deliberately, and with 31 fistulas it was preserved. There was no mortality and virtually no morbidity.

Article Information

Address reprint requests to: Sean Mullan, M.D., Section of Neurosurgery, University of Chicago Hospitals, 950 East 59th Street, Chicago, Illinois 60637.

© AANS, except where prohibited by US copyright law.

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Figures

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    Left: Lateral diagram emphasizing the anteroinferior and posterosuperior cavities. The anteroinferior corner is free of nerves. Right: Schematic view from above. The posterosuperior sac is smaller and is encumbered by the third, fourth, fifth and sixth nerves.

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    Angiogram of a 34-year-old woman 6 weeks after receiving a blow to the eye. Note the large superior ophthalmic vein, small inferior vein, and common entry into the sinus. The superior and inferior petrosal sinuses are prominent. Pterygoid filling is relatively small.

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    Diagrams of the superior orbital fissure. Note isolation of the ophthalmic vein from neighboring nerves.

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    Angiograms of a patient with a spontaneous fistula and a sixth-nerve palsy without proptosis. Left: The fistula drains exclusively into the pterygoid plexus (single arrow). There is no filling of the ophthalmic vein or of the petrosal sinus, although there is a massive posterior bulge (double arrow). The site of the fistula is not evident. Center: At six frames per second the fistulous point was identified posteriorly rather than inferiorly as anticipated (arrow). Right: Intraoperative angiogram. Note temporal lobe retractor. Top and bottom needles are markers (arrows). The fistula is sealed.

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    Angiograms of a 52-year-old man who developed moderate proptosis of right eye 2 days after a fight, but by 5 days the left eye was involved and soon became proptosed and chemotic. Drainage was mostly posteriorly, crossing over the midline to fill the left cavernous sinus and cause more severe symptoms on the contralateral side. Left: Preoperative angiogram showing no filling of the cerebral arteries. Right: The fistula is occluded by transjugular balloon. After 5 days the balloon was deflated because of mild trigeminal pain. There has been no return of the fistula for over 2 years.

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    Angiograms of a 61-year-old man 1 year after the spontaneous onset of a fistula. Despite the small size of the fistula, ophthalmoplegia, proptosis, and chemosis were very severe. There was no adequate posterior or inferior drainage. Left: Preoperative radiogram. Right: Massive array of clips in this, our first anterior Gelfoam occlusion, represent the anxiety of the surgeon rather than the vascularity of the problem. A remarkable resolution of symptoms occurred within 2 weeks.

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    Diagram showing the anterior extradural technique. Upper: The foramen rotundum is located. Center: The bone between fissures is drilled out. Lower: An incision is made at the point of entry into the sinus.

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    Angiogram, transorbital view, of a posttraumatic anterior compartment fistula in a 46-year-old woman. Note the narrow point of entry into the sinus (left orbital view), the importance of which was not recognized at the time. An intraorbital mobilization of the vein resulted in delayed resolution of proptosis 3 months after occlusion (unlike the 2-week resolution in the patient shown in Fig. 4). Single arrow indicates the sinus, double arrow shows the ophthalmic exit.

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    Diagram of the anterior extradural technique. a: schematic transverse section at point of entry of the vein into the sinus. b: A very small incision is made. c: Bleeding is prevented by pressure of cotton-occluded sucker. d: Piecemeal insertion of small thrombogenic plugs into the sinus.

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    Angiograms of a traumatic aneurysm and fistula in a 22-year-old man following a boating accident. Left: Preoperative angiogram. Center: Progressive enlargement of aneurysm 3 weeks later as shown by intraoperative retrograde superficial temporal angiography. Note initial dural markers to outline the presumed course of artery (arrows). Right: Intraoperative venography to verify that the thrombogenic wire did not enter the artery. Some markers have been removed having served their purpose.

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    Angiograms of a severe bilateral (independent) fistula in a 21-year-old man following a serious car accident. Upper Left: Left side. The site of the leak not seen. Upper Right: Intraoperative angiogram suggesting that the fistula is occluded. Note markers to indicate line of artery. Insertion of lateral wire was safely centered on the anterior inferior marker. Some contrast material is seen in the upper wire (arrow). A subtotal carotid clamp for a few days might have made the occlusion complete at this stage but was not used. Lower Right: A slow increase of ophthalmoplegia occurred. Initial lateral wire has been compressed anteroinferiorly (arrows). An “aneurysm” with some residual posterior drainage has formed. A second operative wire insertion obliterated the “aneurysm.” A third sealed the contralateral fistula.

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    Angiograms of a fistula persisting in a 26-year-old woman 2 years after a car accident, despite carotid ligature, and muscle embolization (note clip on embolus in sac). Left: Preoperative angiogram. The fistula fills from the vertebral artery via the posterior communicating artery. Center: Under local anesthesia the internal carotid and ophthalmic arteries were clipped intradurally. The fistula continues to fill from a reticulum around the internal carotid artery in the neck. Right: Subtracted radiograph showing occlusion by 27 ft of phosphor bronze wire (arrows). The middle cerebral artery is supplied by the posterior communicating artery and by external carotid anastomosis.

References

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Parkinson D: Carotid cavernous fistula: direct repair with preservation of the carotid artery. Technical note. J Neurosurg 38:991061973Parkinson D: Carotid cavernous fistula: direct repair with preservation of the carotid artery. Technical note. J Neurosurg 38:99–106 1973

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