- Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya shi, Shizuoka 418-0021, Japan
Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya shi, Shizuoka 418-0021, Japan
DOI:10.4103/2152-7806.130772Copyright: © 2014 Hasegawa H. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Hasegawa H, Inoue T, Tamura A, Saito I. Urgent treatment of severe symptomatic direct carotid cavernous fistula caused by ruptured cavernous internal carotid artery aneurysm using high-flow bypass, proximal ligation, and direct distal clipping: Technical case report. Surg Neurol Int 15-Apr-2014;5:49
How to cite this URL: Hasegawa H, Inoue T, Tamura A, Saito I. Urgent treatment of severe symptomatic direct carotid cavernous fistula caused by ruptured cavernous internal carotid artery aneurysm using high-flow bypass, proximal ligation, and direct distal clipping: Technical case report. Surg Neurol Int 15-Apr-2014;5:49. Available from: http://sni.wpengine.com/surgicalint_articles/urgent-treatment-of-severe-symptomatic-direct-carotid-cavernous-fistula-caused-by-ruptured-cavernous-internal-carotid-artery-aneurysm-using-high-flow-bypass-proximal-ligation-and-direct-distal-clipp/
Background:Direct carotid cavernous fistula (CCF) secondary to ruptured carotid cavernous aneurysms (CCAs) is rare, but patients with this condition who develop acutely worsening and severe neuro-ophthalmic symptoms require urgent treatment. Endovascular methods are the first-line option, but this modality may not be available on an urgent basis.
Case Description:In this article, we report a 45-year-old female with severe direct CCF due to rupture of the CCA. She presented with intractable headache and acute worsening of double vision and visual acuity. Emergent radiographic study revealed high-flow fistula tracked from the CCA toward the contralateral cavernous sinus and drained into the engorged left superior orbital vein. To prevent permanent devastating neuro-ophthalmic damages, urgent high-flow bypass with placement of a radial artery graft was performed followed by right cervical internal carotid artery (ICA) ligation and the clipping of the ICA at the C3 portion, proximal to the ophthalmic artery. In the immediate postoperative period, her symptoms resolved and angiography confirmed patency of the high-flow bypass and complete occlusion of the CCF.
Conclusion:With due consideration of strategy and techniques to secure safety, open surgical intervention with trapping and bypass is a good treatment option for direct severe CCF when the endovascular method is not available, not possible, or is unsuccessful.
Keywords: Carotid cavernous aneurysm, carotid cavernous fistula, high-flow bypass, intracranial aneurysm
Among all types of carotid cavernous fistulas (CCFs), especially direct CCF by carotid cavernous aneurysm (CCA) rupture sometimes requires urgent treatment due to acute cranial nerve and visual impairment, epistaxis, and, most devastatingly, subarachnoid hemorrhage.[
History and examination
A 45-year-old female presented to our hospital with rapidly progressive double vision. She had a history of a right CCA (15 mm in diameter) [
On the day of admission, MR imaging (a), right carotid angiogram (b), and CT (c) revealed an engorged right SOV (yellow arrows) due to direct CCF secondary to ruptured right CCA. Postoperatively, MR imaging (d), right carotid angiogram (e) and CT (f) revealed disappearance of the engorged SOV and no sign of CCF. White arrowheads indicate the patent radial artery graft
Standard neuroanesthesia with somatosensory evoked potentials (SSEP) of the left extremities was induced. With right cervical carotid bifurcation exposure, a curvilinear fronto-temporal skin incision was made, and the superficial temporal artery (STA) was meticulously prepared under a microscope. The RA graft was harvested concurrently by another surgeon. A fronto-temporal craniotomy was performed, and a subzygomatic tunnel was made for the RA graft. The Sylvian fissure was fully split under microscope, and the M1, M2, and M3 portions of the middle cerebral artery (MCA) and the supraclinoidal internal carotid artery (ICA) were exposed. First, an “insurance” STA-M4 bypass was made distal to the M2 portion for RA graft anastomosis.[
The upper picture is the final view of operation and the lower is its illustration. After removing the anterior clinoid process and opening the cavernous sinus, internal carotid artery was able to be trapped between cervical and C3 portion and the ruptured aneurysm got isolated from the circulation. Flow of the ipsilateral ICA was replaced with that of the ECA-RA-M2 bypass. The “insurance” STA-M3 bypass was performed to minimize ischemic damages during the RA-M2 bypass procedure
Immediately after the operation, auscultation over the left eye confirmed disappearance of the ocular bruit. Furthermore, chemosis and exophthalmos resolved. Postoperative angiography confirmed patency of the high-flow bypass and complete occlusion of the CCF. MR imaging revealed no significant cerebral infarction in the revascularized distal right ICA area and showed marked shrinkage of the formerly engorged left SOV [Figure
This technical case report shows a successful urgent surgical repair of severe direct CCF due to ruptured CCA of relatively young female patient.
CCAs are relatively benign lesions and are associated with an extremely low risk of fatal subarachnoid hemorrhage when compared with intracranial aneurysms.[
The goal of CCF treatment is to completely occlude the fistula while simultaneously preserving normal blood flow through the ICA. Endovascular embolization of the fistula is now the first-line treatment modality.[
As for the open surgical approaches, direct clipping of CCAs is extremely challenging, given the complex surrounding structures. For example, it is nearly impossible to avoid manipulating/injuring the cranial nerves when creating a direct surgical corridor for aneurysm clipping. In addition, lengthy temporal occlusion and multiple complex clipping are necessary for direct clipping of such aneurysms, leading to a risk of devastating distal ischemia. In contrast, distal bypass with parent vessel occlusion can completely exclude the aneurysms from the circulation, promptly inducing thrombosis inside aneurysms, and can be performed with predictable ischemia time and a relatively low complication rate, obviating the dangers associated with direct complex aneurysm manipulation.[
Although high-flow bypass procedure is regarded as complex and technically challenging, various previous studies have demonstrated its relative safety, excellent long-term graft patency, as well as acceptable morbidity and mortality rates.[
Although the unavailability of urgent endovascular methods was the main reason for direct surgical intervention in the present case, other reasons to consider direct surgical intervention include the possible disadvantages of endovascular methods and the effectiveness, safety, and durability of open surgical treatment, particularly in stable and/or young patients. However, this is just a case report and further research is needed to validate the conditions in which these respective approaches should be optimally used.
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