Minimally Invasive Keyhole Approach for Removal of a Migratory Balloon Complicated by Endovascular Embolization of a Carotid-Cavernous Fistula

Abstract

Purpose: This report presents our experience in using a minimally invasive keyhole approach to remove a migratory balloon in the cerebral artery in one patient. Case Report: A 19-year-old male suffered from carotid-cavernous fistula after craniofacial trauma two months previously. The patient received endovascular embolization of a carotid-cavernous fistula with detachable balloons. Unfortunately, migration of one balloon to the right middle cerebral artery (MCA) at the M1-M2 junction was noted after detaching the balloon during this procedure. Volume expansion, anticoagulation therapy and an emergency pterional keyhole approach with removal of the displaced balloon were performed successfully. Transient left hemiparesis due to temporary occlusion of the right middle cerebral artery by the balloon was promptly alleviated. There was no definite neurological sequel after the operation. Conclusions: Although detachable balloon embolization is the best initial treatment of direct carotid-cavernous fistulas, it is likely to migrate to downstream cerebral arteries. We recommend a minimally invasive pterional keyhole approach as a good alternative for treating such endovascular complications to improve outcome.

Carotid-cavernous fistula - keyhole - migratory balloon - pterion

References

• 1 Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT. Classification and treatment of spontaneous carotid-cavernous sinus fistulas.  J Neurosurg. 1985;  62 248-256
• 2 Fattahi TT, Brandt MT, Jenkins WS, Steinberg B. Traumatic carotid-cavernous fistula: pathophysiology and treatment.  J Craniofac Surg. 2003;  14 240-246
• 3 Cheng WY, Shen CC. Minimally invasive approaches to treat simultaneous occurrence of glioblastoma multiforme and intracranial aneurysm - case report.  Minim Invas Neurosurg. 2004;  47 181-185
• 4 Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels.  J Neurosurg. 1974;  41 125-145
• 5 Debrun G, Lacour P, Vinuela F, Fox A, Drake CG, Caron JP. Treatment of 54 traumatic carotid-cavernous fistulas.  J Neurosurg. 1981;  55 678-692
• 6 Berthelsen B, Svendsen P. Treatment of direct carotid-cavernous fistulas with detachable balloons.  Acta Radiol. 1987;  28 683-691
• 7 Negoro M, Kageyama N, Ishigauchi T. Cerebrovascular occlusion by catheterization and embolization: clinical experience.  AJNR. 1983;  4 362-365
• 8 Tress BM, Thomson KR, Apsimon HT, King I, Brownbill D, Klug GL, Crawford B. Treatment of caroticocavernous fistulae with detachable balloons introduced by percutaneous catheterization.  Med J Aust. 1983;  4 373-377
• 9 Tsai FY, Hieshima GB, Mehringer CM, Grinnell V, Pribram HW. Delayed effects in the treatment of carotid-cavernous fistulas.  AJNR. 1983;  4 357-361
• 10 Lewis AI, Tomsick TA, Tew Jr JM, Lawless MA. Long-term results in direct carotid-cavernous fistulas after treatment with detachable balloons.  J Neurosurg. 1996;  84 400-404
• 11 Lee, ST, Hsu HH, Ng SH, Wong HF. Recurrent traumatic carotid-cavernous fistula caused by rupture of the detachable balloon.  J Trauma. 1998;  45 969-971
• 12 Peeters FL, van der Werf AJ. Detachable balloon technique in the treatment of direct carotid-cavernous fistulas.  Surg Neurol. 1980;  14 11-19
• 13 Swann KW, Heros RC, Debrun G, Nelson C. Inadvertent middle cerebral artery embolism by a detachable balloon: management by embolectomy.  Case report. J Neurosurg. 1986;  64 309-312
• 14 Chalif DJ, Flamm ES, Berenstein A, Choi IS. Microsurgical removal of a balloon embolus to the internal carotid artery.  Case report. J Neurosurg. 1983;  58 112-116
• 15 Langford KH, Vitek JJ, Zeiger E. Migration of detachable mini-balloon from the ICA causing occlusion of the MCA.  Case report. J Neurosurg. 1983;  58 430-434

Correspondence