Is the retrograde access for endovascular treatment of a traumatic carotid cavernous fistula associated with dissection of the ipsilateral carotid possible?

This is a case demonstrating a combined traumatic lesion of the internal carotid artery (dissection and a carotid cavernous fistula [CCF]) in a patient who was beaten during a robbery and, while trying to escape, was hit by a vehicle. Endovascular approach for the treatment was chosen using the retrograde access from the vertebral artery to the cavernous sinus by posterior communicating (Pcom) artery due to the occlusion of the ipsilateral internal carotid. Because the artery access by the internal carotid was impossible, retrograde approach by vertebral artery and Pcom artery was done to treat the direct CCF. A patient presented with left hemiplegia and proptosis, chemosis, right eye ptosis. Computed tomography (CT) and CT angiography revealed a CCF of the right carotid. An arterial retrograde endovascular approach by the vertebral artery was used for CCF occlusion with coils. We present a rare case of a combined traumatic cerebrovascular lesion, right carotid artery dissection and a right direct CCF treated by a retrograde endovascular approach by the vertebral artery through the Pcom artery to reach the fistula point and achieved a complete cure of the CCF.

How to differentiate intracranial atherosclerotic disease or vasospasms after mechanical thrombectomy. Be patient or vasodilator is the secret?

Here we describe a successful mechanical thrombectomy (MT) for acute large vessel occlusion in stroke treatment with one passage (thrombolysis in cerebral infarction, TICI 3). Immediately after the withdrawing of the stent retriever, a narrowing of the middle cerebral artery was diagnosed. The rate of vasospasms during this procedure can be as higher as 41% (range from 6-41%). Here we describe our protocol when a narrowing of the artery is visualized after a stent retriever is withdrawn. A patient presented in our emergency room with National Institute of Health Stroke Scale (NIHSS) of 21, Alberta Stroke Program Early CT Score (ASPECTS) 8, computed tomography angiography revealed occlusion of the M1 segment and MT was indicated. One passage TICI Ⅲ was achieved. After that, the image showed a narrowing of the artery. We present one case of a spasm after stent retriever technique for MT, we injected vasodilator and the artery became normal in a few minutes differentiating between atheromatous stenosis and vasospasm. We present a technical note that can help to make the differentiation of vasospasm or atheromatous disease after MT with the stent retriever technique.