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

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Usefulness of Intravascular Ultrasonography Monitoring of Coil Embolization for Traumatic Direct Carotid-Cavernous Fistula —Case Report— Neurol Med Chir (Tokyo) 49, 604¿607, 2009 Usefulness of Intravascular Ultrasonography Monitoring of Coil Embolization for Traumatic Direct Carotid-Cavernous Fistula —Case Report— 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 devel- oped 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 su- perficial 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 in- ternal 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 in- ferior 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 superfi- cial 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 ar- rows) 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 emboli- zation 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 oc- clusion 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 transar- terial 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
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