Bilateral Traumatic Caroticocavernous Fistulas: A Case Report and Review of the Literature.

A traumatic caroticocavernous fistula (CCF) is an acquired, abnormal communication between the internal carotid artery and the cavernous sinus, secondary to trauma. This rare condition can initially be misdiagnosed, because its presentation shares features common to those of facial trauma, which can result in serious complications. We describe a case of bilateral CCF in an adult patient after a road traffic accident.

Transorbital penetrating head injury by a wooden chopstick in the cavernous sinus: a case report and literature review.

Penetrating head injury is a relatively rare condition associated with high morbidity and mortality. Although the immediate treatment of penetrating head injury is needed, surgical strategies are varied based on the trajectory of the penetrating objects in the cranium. We present a case of 24-year-old man who sustained a transorbital penetrating injury caused by a wooden chopstick. Neuroimages revealed a linear lesion extending from the left intraorbital segment to the cavernous sinus passing through the superior orbital fissure. The foreign body was successfully removed via the transcranial approach without complications. A careful management based on the perioperative images and correct diagnosis is necessary to avoid unfavorable complications. Four cases of transorbital penetrating injuries have been previously reported, in which the foreign body penetrated through the superior orbital fissure and lodged in the cavernous sinus. The frontotemporal craniotomy with extradural approach can be a useful option to remove foreign bodies around the cavernous sinus regions.

Bilateral Traumatic Carotid-Cavernous Fistula in a Child: Corkscrew Eyelid Vessels as an Indicator of Severe Congestion.

An 11-year-old girl presented with bilateral traumatic caroticocavernous fistula associated with corkscrew eyelid vessels, which were considered indicators of severe congestive disease in this case. Coil embolization was performed; similar to other congestive findings such as proptosis, orbital bruit, increased intraocular pressure, congested scleral and retinal vessels, engorged eyelid vessels resolved immediately after coil embolization. This pediatric case is unique given the caroticocavernous fistula was bilateral and was associated with prominent dilatation of the eyelid vessels, named for the first time as corkscrew eyelid vessels.

Transvenous embolization of a high-flow, posttraumatic fistula between the posterior communicating artery and retroclival venous plexus.

Traumatic injuries of the posterior communicating artery are distinctly rare. We report an unusual case of traumatic tear of the posterior communicating artery with fistulous communication to the adjacent, retroclival venous plexus. The fistula, and an accompanying large venous aneurysm, was completely occluded via transvenous embolization. The patency of the posterior communicating artery was preserved.

Removal of a chopstick out of the cavernous sinus, pons, and cerebellar vermis through the superior orbital fissure.

Penetrating non-missile orbito cranial injuries are rare in a civilian pediatric setting. We describe a case of a trans-orbital penetration by a wooden chopstick deep down into the cerebellar vermis detected at neuroradiological examination in a child presenting for head injury. The foreign body was successfully pulled out in one piece surgically.

Ruptured Persistent Trigeminal Artery Causing Direct Cavernous Sinus Fistula Treated with Pipeline Embolization and Minimal Coiling.

BACKGROUND: Rupture of a persistent trigeminal artery associated with development of a cavernous sinus fistula in a traumatic setting is rare. These arteries are typically treated with coil embolization of the cavernous sinus. CASE DESCRIPTION: We present the case of a 42-year-old woman who developed a direct cavernous carotid fistula after a motor vehicle accident. Angiographic imaging revealed a rupture point of a persistent trigeminal artery as it connected with the cavernous segment of the internal carotid artery, causing a cavernous sinus fistula. Coiling of the cavernous sinus was abandoned after placement of 1 coil because of coil herniation into the internal carotid artery. A Pipeline embolization device was placed to oppose the coil against the intima and keep the lumen open. The combination of coil embolization and flow diversion acutely decreased the fistulous flow. Surprisingly, an angiographic follow-up at 6 months showed complete fistula occlusion despite placement of only 1 coil into the cavernous sinus. CONCLUSIONS: We report a rare case where undercoiling of the cavernous sinus occluded a cavernous sinus fistula because of the adjunct use of a Pipeline embolization device in the presence of a traumatic rupture of a persistent trigeminal artery.

Treatment of traumatic trigeminal-cavernous fistula by coil embolization and compression of carotid artery.

We report a case of a traumatic cavernous fistula supplied by a persistent primitive trigeminal artery. The process of treatment was unique in this case. Fistula was subcompletely occluded by coiling from primitive trigeminal artery. Residual fistula was helped to form thrombosis by compression of the carotid artery with hand in the procedure. Long-term follow-up was satisfactory. Traumatic cavernous fistula supplied by a persistent primitive trigeminal artery could be treated by embolization and temporal compression of the parent artery might be useful for residual minimal fistula.

Surviving Penetrating Brainstem Injury by Bamboo Sticks: Rare Case Reports and a Brief Review of Literature.

BACKGROUND AND IMPORTANCE: Chopsticks are common utensils used in many Asian cultures. However, they sometimes can be used as weapons or can cause accidents, particularly in children. Penetrating transorbital/transpharyngeal intracranial injuries with bamboo sticks are peculiar accidents and are relatively rare. Because of their rarity, the management of such injuries is often complex. We discuss 3 cases of penetration of the brainstem by bamboo sticks, 1 case through the foramen magnum, which, to the best of our knowledge, is the first reported case of such an injury. CLINICAL PRESENTATION: The case of a 50-year-old man who was stabbed with a pair of chopsticks in his left eye is presented. The chopsticks passed through the cavernous sinus, and the patient sustained superior orbital fissure syndrome. The other 2 cases were those of a 4-year-old girl having a similar pattern but different mechanism of injury and a 2-year-old boy who sustained transpharyngeal intracranial injury via the foramen magnum. Computed tomography, magnetic resonance imaging, and computed tomographic angiography (CTA) are the key imaging modalities frequently used to determine the course and extent of brain injury. CONCLUSION: Early surgical exploration by a multidisciplinary team approach is essential for attaining a favorable outcome. All cases demonstrated good postoperative recovery and were successfully managed by removing the foreign body through its trajectory. We discuss and briefly review the literature on patterns, complications, and management issues of these less common injuries.

Orbitocranial Low-Velocity Penetrating Injury: A Personal Experience, Case Series, Review of the literature, and Proposed Management Plan.

BACKGROUND: Orbitocranial penetrating injuries (OPI) are an unfamiliar subset of head injury and are particularly rare in clinical practice. They are usually the result of falls or motor vehicle collisions and occur more commonly in children, who are prone to trauma while playing games improperly. METHODS: We present a retrospective review of 5 cases of OPI treated in the Neurotrauma Department at Xiangya Hospital of Central South University in the last 5 years. Also, we performed comprehensive literature searches using Web of Science and the terms "orbitocranial injury," "penetrating ocular trauma," "penetrating orbital trauma," and "transorbital chopstick penetrating injury" to search for presentation, mechanism of injury, and management of transorbital penetrating injury. RESULTS: In 2 patients, there was right internal carotid artery occlusion while in other 2 patients, the penetrating objects reached the brainstem through the cavernous sinus, resulting in orbital apex syndrome. All patients underwent a thorough physical examination followed by diagnostic imaging. The cases were successfully managed surgically by removing the foreign bodies through their trajectories. CONCLUSIONS: Computed tomography, magnetic resonance imaging, and computed tomography angiography are key imaging modalities that are frequently used to determine the course of the foreign object and the extent of brain tissue injury as well as to rule out vascular injury in these types of cases. Early surgical exploration by a multidisciplinary team approach is essential to attain good recovery and a favorable outcome.

Jugular venous oxygen monitoring: a helpful technique in the early diagnosis of a traumatic carotid-cavernous sinus fistula.

This report describes the early diagnosis of a right traumatic carotid-cavernous sinus fistula (CCSF) in a patient with head injury manifested as an acute increase in right jugular venous oxygen saturation and with no ophthalmic clinical signs. High values of jugular venous oxygen saturation must be cautiously interpreted with the clinical examination and computed tomographic findings to establish an accurate diagnosis of hyperemia with or without a CCSF.

Delayed effects in the treatment of carotid-cavernous fistulas.

Carotid-cavernous fistulas may be classified into: (1) internal carotid, (2) external carotid, or (3) a combination of both. They may result from traumatic or spontaneous rupture of the carotid artery into the cavernous sinus. Intravascular embolization has become the treatment of choice for the management of carotid cavernous fistulas. The authors report the delayed effects after the treatment of carotid-cavernous fistulas with experience of 74 cases over the past 6 years. The delayed effects may be summarized as follows: (1) progressive spontaneous occlusion of the fistula after partial balloon embolization, (2) false aneurysms may decrease in size and be spontaneously sealed off, (3) transient and persistent third or sixth cranial nerve palsy may be seen in about 16% of 74 cases, (4) posttraumatic fibrosis with narrowing of the carotid artery may be apparent after total occlusion of the fistula, (5) a prematurely deflated balloon may be dislodged into the carotid artery or its branch, and (6) spontaneous obliteration of common channels from internal carotid artery may occur after total occlusion of external carotid channels in those cases with a combination of internal carotid- and external carotid-cavernous fistulas. Certainly the delayed effect will alter our future planning in the treatment of carotid cavernous fistulas.

Traumatic aneurysm of the internal carotid artery: a late finding presenting as a mass in the sphenoid sinus.

We describe a case of a traumatic aneurysm of the cavernous portion of the internal carotid artery in a patient who had had craniofacial trauma 12 years before. MR and CT revealed a mass in the sphenoid sinus thought to be unrelated to the patient's symptoms. Carotid angiography gave the correct diagnosis.

Treatment of traumatic carotid-cavernous fistula using detachable balloon catheters.

The goal of therapy in patients with traumatic carotid-cavernous fistulas is to occlude the fistula, preferably while maintaining the carotid blood flow. Surgical techniques that treat the fistula remote from the cavernous sinus often cannot maintain carotid patency. Various interventional techniques using detachable balloons have been developed. The most common technique uses the endarterial route, introducing the balloon catheter in the neck or the groin. If the balloon is detached in the cavernous sinus, the carotid blood flow will be preserved. A second approach uses the venous retrograde route through the jugular vein, inferior petrosal sinus, and cavernous sinus. Elegant and safe, this method is appropriate when the fistula drains posteriorly. A third approach involves surgical exposure of the cavernous sinus and direct introduction of the balloon. This is sometimes the only recourse when the fistula has been previously treated with internal carotid ligation.

Platinum wire: a new transvascular embolic agent.

Standard Gianturco and "mini" coils cannot be used with some of the present microcatheter systems. However, occasions arise in which metallic coils would be an ideal embolic agent in vascular structure accessible only to a tracker (2.2-French) catheter system. We performed nine embolization procedures in eight patients with arteriovenous fistulas using platinum coils as an embolic agent. Fistulas were completely occluded in six of the nine cases. In several cases, platinum wire embolization was augmented with other agents. Complications occurred in two cases, neither resulting in permanent neurologic deficits. Advantages of using platinum coils included availability, radioopacity, thrombogenicity, biocompatibility, and delivery through microcatheters, specifically the tracker catheter system.

Fistula of the posterior communicating artery and cavernous sinus.

A 24-year-old man was admitted with conjunctival hyperemia of the left eye and progressive chemosis and proptosis 1 month after a head injury. An angiogram showed an arterial-cavernous sinus fistula of the posterior communicating artery, which was treated with minicoils. The atypical configuration, transvenous embolization, and unusual nature of the communication suggested that communication developed through a newly generated vessel in granulation tissue.

Cerebrovascular occlusion by catheterization and embolization: clinical experience.

Intravascular occlusion by various catheterization techniques was used to treat 27 cases of carotid-cavernous fistula, giant intracavernous aneurysm, and cerebral or dural arteriovenous malformation. Several case reports are presented. The detachable balloon technique proved valuable in the treatment of traumatic carotid-cavernous fistula and giant aneurysm. Calibrated-leak balloon catheterization with fluid embolization was used to treat cerebral arteriovenous malformation. Selection of embolic material is discussed.

Trigeminal-cavernous fistula: Saltzman anatomy revisited.

We report a case of a carotid-cavernous fistula through a persistent trigeminal artery with endovascular treatment, and discuss the Saltzman classification of persistent trigeminal artery anatomy and its importance in treatment of this lesion.

Transarterial embolization of a direct carotid cavernous fistula with Guglielmi detachable coils.

Four patients underwent transarterial embolization of a carotid-cavernous fistula with Guglielmi detachable coils; in three cases as the initial form of treatment and in one case after treatment via transarterial balloon embolization failed. The fistulas were 2 to 3 mm in diameter on pretreatment angiograms. Complete obliteration was achieved in two patients; in the other two, minimal residual flow remained immediately after embolization but disappeared by follow-up angiography. One to four coils were used to occlude the fistulas. The internal carotid artery remained patent in all patients, and there were no complications.

Computed tomography of carotid-cavernous fistula.

Fourteen patients with angiographically-proven carotid-cavernous fistulas were evaluated by computed tomography (CT). Unilateral or bilateral exophthalmos was noted in 12 patients. Slight blurring of the margin of the globe was present in two, presumably due to pulsations of the globe or conjunctival edema. Superior ophthalmic veins were prominent in 12 patients and were often larger on the side of the fistula. Irregularity or absence of contrast enhancement of the superior ophthalmic vein may indicate partial or complete thrombosis. Focal bulging or diffuse distention of the cavernous sinus was noted in nine patients. Enlargement of the extraocular muscles was observed in seven with swelling of the eyelids and edema of the conjunctiva in eight patients. The pattern of venous drainage, type of fistula, and time intervals between trauma, commencement of fistula, and CT scan may affect the CT manifestations of carotid-cavernous fistulas.

Acquired carotid-cavernous fistula caused by traumatic intracavernous rupture of an embryonic anastomosis.

This case of traumatic carotid-cavernous fistula was caused by rupture of a peculiar ipsilateral intracavernous anastomosis between the accessory meningeal artery and the redundant deep recurrent ophthalmic artery. In the opposite cavernous sinus there was an obvious anastomosis between the accessory meningeal artery and the ophthalmic artery, probably located in the lateral part of the cavernous sinus. The patient was successfully treated with transarterial embolization followed by surgery of the cavernous sinus. In light of the vascular embryology, it is possible that unusual embryonic connections between the primitive dorsal ophthalmic artery and the accessory meningeal artery already existed in both cavernous sinus areas.