Carotid-cavernous fistula following percutaneous retrogasserian procedures

Report of two cases

Restricted access

✓ Carotid arterial puncture during percutaneous retrogasserian procedures is a common but usually harmless complication. Strokes, resulting presumably from carotid artery thrombosis, have been reported previously following percutaneous retrogasserian coagulation. The authors report two cases of carotid-cavernous fistula, one following percutaneous radiofrequency rhizotomy and the other after percutaneous retrogasserian block. The latter patient had an anomalous primitive foramen lacerum. Both fistulas were obliterated successfully by intracavernous injection of isobutyl-2 cyanoacrylate, using intra-arterial balloon flotation catheters. Carotid-cavernous fistula is a potentially serious complication of such procedures, and may be more common than realized since small fistulas may close spontaneously.

Article Information

Address reprint requests to: Laligam N. Sekhar, M.D., Department of Neurological Surgery, 9402 Presbyterian University Hospital, 230 Lothrop Street, Pittsburgh, Pennsylvania 15213.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 1. Upper Left: Cerebral angiogram, right internal carotid (ICA) injection, demonstrating the carotid-cavernous fistula. The site of the fistula in the cavernous sinus could not be localized. Upper Right: A calibrated-leak balloon microcatheter was introduced into the right ICA. The inflated balloon at the tip is marked by the large arrow. The site of exit of the catheter from the ICA inside the cavernous sinus is indicated by the small arrow. This point is fairly anterior to the location of the normal foramen ovale and the Gasserian ganglion. Lower: Angiogram performed 2 months after occlusion of the fistula. The anterior bend of the ICA appears slightly thickened because of overlying radiopaque adhesive in the cavernous sinus.

  • View in gallery

    Case 2. Cerebral angiogram, left internal carotid injection, showing a large carotid-cavernous fistula with drainage into the superior ophthalmic vein and into the straight sinus. The site of the fistulous opening could not be located.

  • View in gallery

    Case 2. Upper: Anteroposterior and lateral views obtained during first cyanoacrylate injection. The posterior draining channels into the straight sinus are occluded and no longer seen; drainage into the ophthalmic vein persists. Arrows point to the probable site of fistulous opening (exit site of the balloon catheter from the artery), located posteriorly in the cavernous sinus. Lower: Angiogram after complete occlusion of the cavernous sinus. The veins do not fill any more and cyanoacrylate in the cavernous sinus is seen (black arrows) underlying the carotid artery (white arrow).

References

  • 1.

    Aass ASTenicela R: Inadvertent abducens nerve block during therapeutic trigeminal nerve block. Acta Anesthesiol Scand 20:3593601976Aass AS Tenicela R: Inadvertent abducens nerve block during therapeutic trigeminal nerve block. Acta Anesthesiol Scand 20:359–360 1976

    • Search Google Scholar
    • Export Citation
  • 2.

    Adriani J: Blocking of the cranial nerves in Labat G: Regional Anesthesia. Techniques and Applicationsed 3. Philadelphia/London: WB Saunders1967 pp 7785 (see p 84)Adriani J: Blocking of the cranial nerves in Labat G: Regional Anesthesia. Techniques and Applications ed 3. Philadelphia/London: WB Saunders 1967 pp 77–85 (see p 84)

    • Search Google Scholar
    • Export Citation
  • 3.

    Harris FSRhoton AL Jr: Anatomy of the cavernous sinus. A microsurgical study. J Neurosurg 45:1691801976Harris FS Rhoton AL Jr: Anatomy of the cavernous sinus. A microsurgical study. J Neurosurg 45:169–180 1976

    • Search Google Scholar
    • Export Citation
  • 4.

    Hensell V: Ist die Elektrokoagulation des Ganglion Gasseri auch heute noch berechtigt? Chirurgia 28:5445481957Hensell V: Ist die Elektrokoagulation des Ganglion Gasseri auch heute noch berechtigt? Chirurgia 28:544–548 1957

    • Search Google Scholar
    • Export Citation
  • 5.

    Kerber CWBank WOCromwell LD: Calibrated leak balloon microcatheter: a device for arterial exploration and occlusive therapy. Am J Roentgenol 132:2072121979Kerber CW Bank WO Cromwell LD: Calibrated leak balloon microcatheter: a device for arterial exploration and occlusive therapy. Am J Roentgenol 132:207–212 1979

    • Search Google Scholar
    • Export Citation
  • 6.

    Kirschner M: Zur Elektrochirurgie. Arch Klin Chir 167:7617681931Kirschner M: Zur Elektrochirurgie. Arch Klin Chir 167:761–768 1931

    • Search Google Scholar
    • Export Citation
  • 7.

    Klar E: Über die erfahrungen mit der Elektrokoagulation bei der Trigeminusneuralgie an der Heidelberger Chirurgische Universitätsklinik. Langenbecks Arch Klin Chir 294:7137231960Klar E: Über die erfahrungen mit der Elektrokoagulation bei der Trigeminusneuralgie an der Heidelberger Chirurgische Universitätsklinik. Langenbecks Arch Klin Chir 294:713–723 1960

    • Search Google Scholar
    • Export Citation
  • 8.

    Kubanyi E: Sur le traitement de le névralgie du nerf trijumeau par l'électro-coagulation intracranienne du ganglion de Gasser (d'apres 301 cas). Lyon Chir 41:6816891946Kubanyi E: Sur le traitement de le névralgie du nerf trijumeau par l'électro-coagulation intracranienne du ganglion de Gasser (d'apres 301 cas). Lyon Chir 41:681–689 1946

    • Search Google Scholar
    • Export Citation
  • 9.

    Menzel JPiotrowski WPenzholz H: Long-term results of Gasserian ganglion electrocoagulation. J Neurosurg 42:1401431975Menzel J Piotrowski W Penzholz H: Long-term results of Gasserian ganglion electrocoagulation. J Neurosurg 42:140–143 1975

    • Search Google Scholar
    • Export Citation
  • 10.

    Nugent RGBerry B: Trigeminal neuralgia treated by differential percutaneous radiofrequency coagulation of the Gasserion ganglion. J Neurosurg 40:5175231974Nugent RG Berry B: Trigeminal neuralgia treated by differential percutaneous radiofrequency coagulation of the Gasserion ganglion. J Neurosurg 40:517–523 1974

    • Search Google Scholar
    • Export Citation
  • 11.

    Onofrio MB: Radiofrequency percutaneous Gasserian ganglion lesions. Results in 140 patients with trigeminal pain. J Neurosurg 42:1321391975Onofrio MB: Radiofrequency percutaneous Gasserian ganglion lesions. Results in 140 patients with trigeminal pain. J Neurosurg 42:132–139 1975

    • Search Google Scholar
    • Export Citation
  • 12.

    Parkinson S: A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 23:4744831965Parkinson S: A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 23:474–483 1965

    • Search Google Scholar
    • Export Citation
  • 13.

    Rish BL: Cerebrovascular accident after percutaneous rf thermocoagulation of the trigeminal ganglion. Case report. J Neurosurg 44:3763771976Rish BL: Cerebrovascular accident after percutaneous rf thermocoagulation of the trigeminal ganglion. Case report. J Neurosurg 44:376–377 1976

    • Search Google Scholar
    • Export Citation
  • 14.

    Seeger VW: Genuine und symptomatische Trigeminusneuralgie. Dtsch Med Wochenschr 88:1711751963Seeger VW: Genuine und symptomatische Trigeminusneuralgie. Dtsch Med Wochenschr 88:171–175 1963

    • Search Google Scholar
    • Export Citation
  • 15.

    Siegfried J: 500 percutaneous thermocoagulations of the Gasserian ganglion for trigeminal pain. Surg Neurol 8:1261311977Siegfried J: 500 percutaneous thermocoagulations of the Gasserian ganglion for trigeminal pain. Surg Neurol 8:126–131 1977

    • Search Google Scholar
    • Export Citation
  • 16.

    Sondheimer FK: Basal foramina and canals in Newton THPotts DG (eds): Radiology of the Skull and Brain Vol 1 Book 1. St Louis: CV Mosby1971 pp 287347 (see pp 297–314)Sondheimer FK: Basal foramina and canals in Newton TH Potts DG (eds): Radiology of the Skull and Brain Vol 1 Book 1. St Louis: CV Mosby 1971 pp 287–347 (see pp 297–314)

    • Search Google Scholar
    • Export Citation
  • 17.

    Sunder-Plassmann P: Ergebnisse der Elektrokoagulation des Ganglion Gasseri bei Trigeminusneuralgie. Zentralbl Chir 66:223422361939Sunder-Plassmann P: Ergebnisse der Elektrokoagulation des Ganglion Gasseri bei Trigeminusneuralgie. Zentralbl Chir 66:2234–2236 1939

    • Search Google Scholar
    • Export Citation
  • 18.

    Sweet WH: Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers: facial pain other than trigeminal neuralgia. Clin Neurosurg 23:961021976Sweet WH: Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers: facial pain other than trigeminal neuralgia. Clin Neurosurg 23:96–102 1976

    • Search Google Scholar
    • Export Citation
  • 19.

    Sweet WHWepsic JG: Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers. Part 1: Trigeminal neuralgia. J Neurosurg 40:1431561974Sweet WH Wepsic JG: Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers. Part 1: Trigeminal neuralgia. J Neurosurg 40:143–156 1974

    • Search Google Scholar
    • Export Citation
  • 20.

    Taptas N: Les injections d'alcohol dans le ganglion de Gasser à travers le trou ovale. Presse Med 19:7981911Taptas N: Les injections d'alcohol dans le ganglion de Gasser à travers le trou ovale. Presse Med 19:798 1911

    • Search Google Scholar
    • Export Citation
  • 21.

    Tenicela R: Personal communication1978Tenicela R: Personal communication 1978

  • 22.

    Tew JM JrKeller JT: The treatment of trigeminal neuralgia by percutaneous radiofrequency technique. Clin Neurosurg 24:5575781977Tew JM Jr Keller JT: The treatment of trigeminal neuralgia by percutaneous radiofrequency technique. Clin Neurosurg 24:557–578 1977

    • Search Google Scholar
    • Export Citation
  • 23.

    Tew JM JrMayfield FH: Trigeminal neuralgia: a new surgical approach (percutaneous electrocoagulation of the trigeminal nerve). Laryngoscope 83:109611011973Tew JM Jr Mayfield FH: Trigeminal neuralgia: a new surgical approach (percutaneous electrocoagulation of the trigeminal nerve). Laryngoscope 83:1096–1101 1973

    • Search Google Scholar
    • Export Citation
  • 24.

    Wepsic JG: Complications of percutaneous surgery for pain. Clin Neurosurg 23:4544641976Wepsic JG: Complications of percutaneous surgery for pain. Clin Neurosurg 23:454–464 1976

    • Search Google Scholar
    • Export Citation
  • 25.

    White JCSweet WH: Pain and the Neurosurgeon. A Forty-Year Experience. Springfield, Ill: Charles C Thomas19691000 ppWhite JC Sweet WH: Pain and the Neurosurgeon. A Forty-Year Experience. Springfield Ill: Charles C Thomas 1969 1000 pp

    • Search Google Scholar
    • Export Citation
  • 26.

    Zenker R: I. Die Behandlung der Trigeminusneuralgie unter besonderer Berücksichtigung der Grundlagen, der Ausführung und der Ergebnisse der Punktion und Electrokoagulation des Ganglion Gasseri nach Kirschner. Ergeb Chir Orthop 31:1821938Zenker R: I. Die Behandlung der Trigeminusneuralgie unter besonderer Berücksichtigung der Grundlagen der Ausführung und der Ergebnisse der Punktion und Electrokoagulation des Ganglion Gasseri nach Kirschner. Ergeb Chir Orthop 31:1–82 1938

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 68 68 5
Full Text Views 208 208 1
PDF Downloads 118 118 1
EPUB Downloads 0 0 0

PubMed

Google Scholar