Usefulness of Intravascular Ultrasonography Monitoring of Coil Embolization for Traumatic Direct Carotid-Cavernous Fistula —Case Report—

Neurol Med Chir (Tokyo) 49, 604¿607, 2009

Akimasa NISHIO, Taichiro KAWAKAMI,YutakaMITSUHASHI,KojiHAYASAKI*, Miki KIYAMA**,YuichiTADA**,andKenjiOHATA

Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka; *Department of Neurosurgery, Saiseikai Ibaraki Hospital, Ibaraki, Osaka; **Department of Neurosurgery, Ouekai Katsuragi Hospital, Kishiwada, Osaka

Abstract A 61-year-old woman was admitted for head injury after a traffic accident. Two months later, she developed abducens nerve palsy, chemosis, and pulsatile tinnitus. Right internal carotid angiography

demonstrated a high flow direct carotid-cavernous fistula (CCF) at the C5 portion with reflux into the superficial and deep sylvian veins, superior ophthalmic vein, superior petrosal sinus, and inferior

petrosal sinus. Intravascular ultrasonography (IVUS) revealed a large fistula at the C5 portion of the internal carotid artery (ICA). Coil embolization via transarterial and transvenous approaches under IVUS monitoring was performed. During the procedure, IVUS accurately detected protrusion of a coil into the parent ICA, and the parent artery could be preserved. IVUS monitoring is useful for embolization of direct CCF with coils. Key words: direct carotid-cavernous fistula, embolization, intravascular ultrasound

Introduction paresis. In addition, the coil mass may protrude into the parent artery through the large tear or may obscure the Direct carotid-cavernous fistulas (CCFs) are preferably relationship between cavernous sinus and the nearby par- treated via a transarterial approach, ideally resulting in ent artery, with increased risk of occluding the parent ar- permanent occlusion of the fistula and preservation of the tery. parent internal carotid artery (ICA). Detachable balloons Biplane simultaneous fluoroscopic monitoring of coil quickly became the method of choice to treat CCF follow- deposition provides excellent visualization, but cannot ing introduction in the 1970s,1–3,12,19) with preserved paten- confirm that coils introduced from the venous or arterial cy of the parent ICA in 75–88% of cases.2,4,6,10–13,16) sides do not herniate through the fistula and compromise However, detachable balloons cannot be used if preserva- the ICA lumen. Therefore, the balloon protection of the tion of the parent artery is essential, leading to a search for ICA lumen during coil deposition may be critical. other ways to treat CCF, such as detachable coils and We describe our experience of treating a case of trau- cyanoacrylates.4,8,11) Direct CCFs have been successfully matic direct CCF with GDCs under intravascular occluded with coil embolization via either the trans- ultrasonography (IVUS) monitoring, because the patient arterial or transvenous approach.8,9,14,15,21) Guglielmi could not tolerate ICA occlusion. detachable coil (GDC) is effective for direct CCFs with small fistulas and/or small cavernous sinuses, because a Case Report limited number of GDCs will be required to achieve angio- graphic cure.7,8,21) However, closure of a traumatic CCF A 61-year-old woman was admitted for head injury after a with microcoils from an arterial route poses many traffic accident in August 2007. Two months after the ac- problems. GDCs are not appropriate for a direct CCF with cident, she developed right abducens nerve palsy, chemo- a large tear and/or a large cavernous sinus, because many sis, and pulsatile tinnitus. Right internal carotid an-

GDCs are needed to densely pack the cavernous sinus and giography demonstrated a high flow CCF at the C5 portion to occlude the fistula. The mass effect of the coils in the with reflux into the superficial and deep sylvian veins, su- cavernous sinus may also cause long-term cranial nerve perior ophthalmic vein, superior petrosal sinus, and inferior petrosal sinus (Fig. 1). Received February 3, 2009; Accepted May 7, 2009 Superselective angiography showed a relatively large

604 Coil Embolization for Direct CCF 605

Fig. 1 Right internal carotid angiograms, anteroposterior view (A) and lateral view (B), showing a high flow carotid- cavernous fistula at the C5 portion with reflux into the superficial and deep sylvian veins, superior ophthalmic vein, superior petrosal sinus, and inferior petrosal sinus.

Fig. 3 A–C: Preoperative intravascular ultrasonography (IVUS) scans showing the large fistula (arrow)(A),insertionof the microcatheter (double arrows) into the cavernous sinus through the fistula (B), and protrusion of the coils (triple arrows) into the parent artery during the coil insertion (C). D: Postoperative IVUS scan showing the small cavity (arrowhead) remaining around the fistula.

Fig. 2 Right internal carotid angiograms, anteroposterior view (A) and lateral view (B), immediately after the first embolization showing reduced blood flow in the fistula.

fistula, so closure was initially attempted using balloon- assisted transvenous coil embolization. Unfortunately, the patient could not tolerate balloon occlusion of the ICA. Therefore, the therapeutic strategy was shifted to coil occlusion of the cavernous sinus distal to the fistula, intend- ed to reduce the blood flow through the fistula. An- giography on the next day showed a residual flow through the fistula (Fig. 2). Therefore, a second attempt for transarterial coil insertion was decided. Fig. 4 Postoperative right internal carotid angiograms, an- To prevent coil protrusion into the unprotected ICA, the teroposterior view (A) and lateral view (B), showing complete procedure was monitored by IVUS. An 8 Fr guiding occlusion of the fistula. catheter (Brite Tip Guiding Catheter; J&J Cordis Corpora- tion, Miami, Fla., U.S.A.) was positioned in the right ICA. The long micro-guide wire (Synchro Support-14 Guide- sinus, GDCs (Target Therapeutics, Fremont, Calif., U.S.A.) wire, 300 cm; Boston Scientific Corp., Natick, Mass., were impacted into the cavernous sinus. The coil insertion U.S.A.) was introduced into the right middle cerebral ar- was monitored by IVUS. Protrusion of the coils inside the tery. The IVUS probe (s5TM Imaging System and Eagle ICA was excluded by moving the probe of the IVUS to and Eye Gold Catheter; Volcano Corporation, Rancho Cordo- fro across the fistula. The usefulness of the IVUS monitor- va, Calif., U.S.A.) was mounted onto the micro-guide wire ing was proved by demonstration of a coil protruding into in the ICA. Three-dimensional IVUS revealed a larger the ICA (Fig. 3C). This coil was immediately retrieved. fistula than indicated angiographically (Fig. 3A). We used IVUS demonstrated a residual cavity distal to the fistula the fistulous tract to insert a microcatheter (Excelsiol (Fig. 3D), but control carotid angiography showed com- 1018 Microcatheter, preshaped 909; Boston Scientific plete cessation of the fistulous flow (Fig. 4). Three months Corp.) into the cavernous sinus (Fig. 3B). After positioning later, the patient had not experienced tinnitus or chemo- and securing the tip of the microcatheter in the cavernous sis, and her abducens nerve palsy had resolved. Follow-up

Neurol Med Chir (Tokyo) 49, December, 2009 606 A. Nishio et al. magnetic resonance imaging and angiography showed References total obliteration of the fistula. 1) Debrun G, Lacour P, Caron JP, Hurth M, Comoy J, Keravel Y: Discussion Detachable balloon and calibrated-leak balloon techniques in the treatment of cerebral vascular lesions. J Neurosurg 49: Detection of the location and size of the fistula is im- 635–649, 1978 portant in diagnosis of direct CCFs. Vertebral an- 2) Debrun G, Lacour P, Caron JP, Hurth M, Comoy J, Keravel Y, Laborit G: Experimental approach to the treatment of giography or contralateral carotid angiography with ip- carotid-cavernous fistulas with an inflatable and isolated silateral compression of the ICA is very useful, as is rota- balloon. Neuroradiology 9: 9–12, 1975 tion angiography. Conventional angiography, rotational 3) Debrun G, Lacour P, Vinuela F, Fox A, Drake CG, Caron JP: three-dimensional angiography, and three-dimensional Treatment of 54 traumatic carotid-cavernous fistulas. JNeu- computed tomography can easily detect a small orifice rosurg 55: 678–692, 1981 and the relationships between the ICA, fistula, and caver- 4) Debrun GM, Vinuela F, Fox AJ, Davis KR, Ahn HS: Indica- nous sinus. However, if the orifice of the fistula is larger, tions for treatment and classification of 132 carotid-caver- the size of the fistula can be difficult to detect because of nous fistulas. Neurosurgery 22: 285–289, 1988 the dilated cavernous sinus, and overlapping of the ICA, 5) Diethrich EB, Pauliina Margolis M, Reid DB, Burke A, fistula, and cavernous sinus. In our case, the larger fistula Ramaiah V, Rodriguez-Lopez JA, Wheatley G, Olsen D, Vir- mani R: Virtual histology intravascular ultrasound assess- prevented precise evaluation of the relationship between ment of carotid artery disease: the Carotid Artery Plaque the fistula and venous side, despite angiography from Virtual Histology Evaluation (CAPITAL) study. J Endovasc several directions including the three-dimensional evalua- Ther 14: 676–686, 2007 tion. In contrast, IVUS clearly demonstrated the large 6) Goto K, Hieshima GB, Higashida RT, Halbach VV, Bentson fistula and the relationship with the venous side precisely. JR, Mehringer CM, Pribram HF: Treatment of direct carotid- Previously, IVUS had been exclusively used in the field cavernous sinus fistulae: various therapeutic approaches of interventional cardiology for the detection of in-stent and results in 148 cases. Acta Radiol Suppl 369: 576–579, restenosis with intimal hyperplasia, in-stent thrombosis, 1986 appropriate stent apposition, intravascular disease, and 7) GuglielmiG,ViãnuelaF,BrigantiF,DuckwilerG:Carotid- the characteristics of atherosclerotic plaques.17,22) The neu- cavernous fistula caused by a ruptured intracavernous aneurysm: endovascular treatment by electrothrombosis rovascular system is more vulnerable to embolic ischemic with detachable coils. Neurosurgery 31: 591–596, 1992 24) complications, with more tortuous and smaller vessels. 8) Halbach VV, Higashida RT, Barnwell SL, Dowd FC, Hieshi- Moreover, the IVUS catheters are not thin or soft enough ma GB: Transarterial platinum coil embolization of carotid- for compatibility with intracranial navigation. These fac- cavernous fistulas. AJNR Am J Neuroradiol 12: 429–433, tors have delayed introduction of IVUS into endovascular 1991 neurosurgical procedures.23,24) However, the extracranial 9) Halbach VV, Higashida RT, Hieshima GB, Hardin CW, Yang vessels are larger and less tortuous, so do not require high PJ: Transvenous embolization of direct carotid cavernous trackability for handling the IVUS catheter. Therefore, fistulas. AJNR Am J Neuroradiol 9: 741–747, 1988 IVUS was initially introduced in carotid stenting and 10) Higashida RT, Halbach VV, Tsai FY, Norman D, Pribram plaque analysis to avoid distal embolization.5,18) IVUS was HF, Mehringer CM, Hieshima GB: Interventional neurovas- cular treatment of traumatic and vertebral lesion: results in also used to demonstrate multiple channels formed by a 234 patients. AJR Am J Roentgenol 153: 577–582, 1989 dural arteriovenous fistula and to define the exact 11) Lewis AI, Tomsick TA, Tew JM: Management of 100 con- 20) fistulous site for accurate transvenous embolization. secutive direct carotid-cavernous fistulas: results of treat- IVUS was used to monitor embolization of vertebral ar- ment with detachable balloons. Neurosurgery 36: 239–245, teriovenous fistula, and was useful for detection of the di- 1995 ameter of the involved vessels, the fistula site, and the vas- 12) Lewis AI, Tomsick TA, Tew JM, Lawless MA: Long-term cular architecture around the fistula site.26) IVUS-guided results in direct carotid cavernous fistula treatment with stent angioplasty of an extracranial vertebral artery dis- detachable balloons. J Neurosurg 84: 400–404, 1996 section was valuable for understanding the intravascular 13) Luo CB, Teng MMH, Chang FC, Chang CY: Transarterial environment, confirming the true lumen, and evaluating balloon-assisted n-butyl-2-cyanoacrylate embolization of direct carotid cavernous fistulas. AJNR Am J Neuroradiol 27: stent apposition.25) Intracranial IVUS remains challeng- 1535–1540, 2006 ing, and requires a device with high trackability to over- 14) Luo CB, Teng MMH, Yen DHT, Chang FC, Lirng JF, Chang come the tortuous and long pathway to the target. More CY: Endovascular embolization of recurrent traumatic low-profile devices with better trackability are essential carotid-cavernous fistulas managed previously with detach- for further refinement of the technique. able balloons. JTrauma56: 1214–1220, 2004 In the present case, balloon-assisted transarterial coil 15) MardenFA,SinhaRoyS,MalischTW:Anovelapproachto embolization failed because the patient suffered con- direct carotid cavernous fistula repair: Hydrocoil-assisted sciousness disturbance and hemiparesis within a few sec- revision after balloon reconstruction. Surg Neurol 64: onds, so the balloon-assist coil embolization was not con- 140–143, 2005 tinued. IVUS could detect protrusion of the coils into the 16) Norman D, Newton TH, Edwards MS, DeCaprio V: Carotid- cavernous fistula: closure with detachable silicone balloons. parent ICA during deposition of the coils in three dimen- Radiology 149: 149–157, 1983 sions by moving the probe of the IVUS distal to proximal 17) OhlmannP,MintzGS,KimSW,PichardAD,SatlerLF,Kent across the fistula.

Neurol Med Chir (Tokyo) 49, December, 2009 Coil Embolization for Direct CCF 607

KM,SuddathWO,WaksmanR,WeissmanNJ:Intravascular ultrasound identification of intraluminal embolic plaque ultrasound findings in patients with restenosis of sirolimus- material during carotid angioplasty with stenting. Catheter and paclitaxel-eluting stents. Int J Cardiol 125: 11–15, 2008 Cardiovasc Interv 68: 853–857, 2006 18) Schiro BJ, Wholey MH: The expanding indications for vir- 24) Wehman JC, Holmes DR Jr, Hanel RA, Levy EI, Hopkins LN: tual histology intravascular ultrasound for plaque analysis Intravascular ultrasound for intracranial angioplasty and prior to carotid stenting. J Cardiovasc Surg (Torino) 49: stent placement: technical case report. Neurosurgery 59(4 729–736, 2008 Suppl 2): ONSE481–483, 2006 19) Serbinenko FA: Balloon catheterization and occlusion of 25) YoonWK,KimYW,KimSD,ParkIS,BaikMW,KimSR:In- major cerebral vessels. J Neurosurg 41: 125–145, 1974 travascular ultrasonography-guided stent angioplasty of an 20) Shindo A, Kawanishi M, Masada T, Kawai N, Tamiya T, Na- extracranial vertebral artery dissection. Case report. JNeu- gao S: [Usefulness of intravascular ultrasound in emboliza- rosurg 109: 1113–1118, 2008 tion of dural arteriovenous fistula: a case report]. No Shinkei 26) Yoshioka T, Kitagawa N, Morikawa M, Hayashi K, Izumo T, Geka 31: 1323–1329, 2003 (Jpn, with Eng abstract) Nakamoto M, Kaminogo M, Nagata I: [Successful trans- 21) Siniluoto T, Seppanen S, Kuurne T, Wilholm G, Leinonen S, arterial occlusion of a vertebral arteriovenous fistula with Svendsen P: Transarterial embolization of a direct carotid aid of intra vascular ultra sound (IVUS) and balloon cavernous fistula with Guglielmi detachable coils. AJNR Am catheter]. No Shinkei Geka 32: 597–602, 2004 (Jpn, with Eng J Neuroradiol 18: 519–523, 1997 abstract) 22) TanakaK,CarlierSG,MintzGS,SanoK,LiuX,FujiiK,de Ribamar Costa J Jr, Lui J, Moses JW, Stone GW, Leon MB: The accuracy of length measurements using different in- Address reprint requests to: Akimasa Nishio, M.D., Department of travascular ultrasound motorized transducer pullback sys- Neurosurgery, Osaka City University Graduate School of tems. Int J Cardiovasc Imaging 23: 733–738, 2007 Medicine, 1–4–3 Asahi–machi, Abeno–ku, Osaka 545–8585, 23) Wehman JC, Holmes DR Jr, Ecker RD, Sauvageau E, Japan. Fahrbach J, Hanel RA, Hopkins LN: Intravascular e-mail: m3275727＠med.osaka-cu.ac.jp

Neurol Med Chir (Tokyo) 49, December, 2009