J Neurol Surg A Cent Eur Neurosurg 2023; 84(05): 483-488
DOI: 10.1055/s-0041-1741547
Technical Note

Onyx Embolization of an Indirect Carotid–Cavernous Fistula with Cortical Venous Reflux: Technical Note

1   Department of Neurosurgery, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Bogotá, Colombia
2   Rosario University School of Medicine, Bogotá, Colombia
,
1   Department of Neurosurgery, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Bogotá, Colombia
2   Rosario University School of Medicine, Bogotá, Colombia
,
Humberto Madrinan-Navia
1   Department of Neurosurgery, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Bogotá, Colombia
2   Rosario University School of Medicine, Bogotá, Colombia
,
William Mauricio Riveros
1   Department of Neurosurgery, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Bogotá, Colombia
2   Rosario University School of Medicine, Bogotá, Colombia
,
Alberto Caballero
1   Department of Neurosurgery, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Bogotá, Colombia
2   Rosario University School of Medicine, Bogotá, Colombia
› Author Affiliations

Abstract

Background Indirect carotid–cavernous fistulas (iCCFs) are shunts between meningeal branches of the internal carotid and/or the external carotid arteries and the cavernous sinus. They account for 83% of all carotid–cavernous fistulas (CCFs). Symptomatic iCCFs and those with increased risk of hemorrhage should be treated. Transvenous endovascular treatment is the preferred treatment modality. However, in complex cases, a combination of transarterial and transvenous approaches (multimodal treatment) is required.

Methods A middle-aged woman presented with signs of increased intraocular pressure, blurry vision, diplopia, left proptosis, chemosis, conjunctival injection, ptosis, and cranial nerve VI palsy. Imaging confirmed the presence of a Barrow type D and Thomas type 4 iCCF with cortical venous reflux (CVR).

Results The patient underwent transarterial and transvenous onyx embolization of the shunt, achieving a complete obliteration of the fistula. No complications occurred and the patient had a satisfactory postprocedural evolution.

Conclusion Multimodal onyx embolization is an effective option for the treatment of a complex symptomatic iCCF. If CVR is identified, these lesions should be promptly treated to prevent hemorrhage secondary to rupture.



Publication History

Received: 04 February 2021

Accepted: 01 November 2021

Article published online:
24 January 2022

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  • References

  • 1 Elhammady MS, Ambekar S, Heros RC. Epidemiology, clinical presentation, diagnostic evaluation, and prognosis of cerebral dural arteriovenous fistulas. Handb. Clin. Neurol 2017; 143: 99-105
  • 2 Stéphan S, Blanc R, Zmuda M. et al. Endovascular treatment of carotid-cavernous fistulae: long-term efficacy and prognostic factors. J Fr Ophtalmol 2016; 39 (01) 74-81
  • 3 Al-Mufti F, Amuluru K, El-Ghanem M. et al. Spontaneous bilateral carotid-cavernous fistulas secondary to cavernous sinus thrombosis. Neurosurgery 2017; 80 (04) 646-654
  • 4 Alexander MD, Halbach VV, Hallam DK. et al. Long-term outcomes of endovascular treatment of indirect carotid cavernous fistulae: superior efficacy, safety, and durability of transvenous coiling over other techniques. Neurosurgery 2019; 85 (01) E94-E100
  • 5 Thomas AJ, Chua M, Fusco M. et al. Proposal of venous drainage-based classification system for carotid cavernous fistulae with validity assessment in a multicenter cohort. Neurosurgery 2015; 77 (03) 380-385 , discussion 385
  • 6 Sur S, Menaker SA, Alvarez C, Chen S, Shah SS, Peterson EC. et al. Multimodal management of carotid-cavernous fistulas. World Neurosurg 2020; 133: e796-e803
  • 7 Ringer AJ, Salud L, Tomsick TA. Carotid cavernous fistulas: anatomy, classification, and treatment. Neurosurg Clin N Am 2005; 16 (02) 279-295 , viii
  • 8 Gonzalez Castro LN, Colorado RA, Botelho AA, Freitag SK, Rabinov JD, Silverman SB. Carotid-cavernous fistula: a rare but treatable cause of rapidly progressive vision loss. Stroke 2016; 47 (08) e207-e209
  • 9 Kiliç T, Elmaci I, Bayri Y, Pamir MN, Erzen C. Value of transcranial Doppler ultrasonography in the diagnosis and follow-up of carotid-cavernous fistulae. Acta Neurochir (Wien) 2001; 143 (12) 1257-1264 , discussion 1264–1265
  • 10 Chaudhry IA, Elkhamry SM, Al-Rashed W, Bosley TM. Carotid cavernous fistula: ophthalmological implications. Middle East Afr J Ophthalmol 2009; 16 (02) 57-63
  • 11 Jung KH, Kwon BJ, Chu K. et al. Clinical and angiographic factors related to the prognosis of cavernous sinus dural arteriovenous fistula. Neuroradiology 2011; 53 (12) 983-992
  • 12 Bink A, Goller K, Lüchtenberg M. et al. Long-term outcome after coil embolization of cavernous sinus arteriovenous fistulas. AJNR Am J Neuroradiol 2010; 31 (07) 1216-1221
  • 13 Elhammady MS, Peterson EC, Aziz-Sultan MA. Onyx embolization of a carotid cavernous fistula via direct transorbital puncture. J Neurosurg 2011; 114 (01) 129-132
  • 14 Holland LJ, Mitchell Ranzcr K, Harrison JD, Brauchli D, Wong Y, Sullivan TJ. Endovascular treatment of carotid–cavernous sinus fistulas: ophthalmic and visual outcomes. Orbit 2019; 38: 290-299
  • 15 Williams ZR. Carotid-cavernous fistulae: a review of clinical presentation, therapeutic options, and visual prognosis. Int Ophthalmol Clin 2018; 58 (02) 271-294
  • 16 Zeng T, Lin YF, Shi SS. Multimodal endovascular treatment for traumatic carotid-cavernous fistula. Chin J Traumatol 2013; 16 (06) 334-338
  • 17 Morton RP, Tariq F, Levitt MR, Nerva JD, Mossa-Basha M, Sekhar LN. et al. Radiographic and clinical outcomes in cavernous carotid fistula with special focus on alternative transvenous access techniques. J Clin Neurosci 2015; 22: 859-864
  • 18 Larson JJ, Tew Jr JM, Tomsick TA, van Loveren HR. Treatment of aneurysms of the internal carotid artery by intravascular balloon occlusion: long-term follow-up of 58 patients. Neurosurgery 1995 Jan;36(1):26-30; discussion 30. PMID: 7708164