Treatment of post-traumatic carotid-cavernous fistulas using pipeline embolization device assistance.
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ABSTRACT:
SUBMITTER: Pradeep N
PROVIDER: S-EPMC4550904 | biostudies-other | 2015 Aug
REPOSITORIES: biostudies-other
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Project description:Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options.
| S-EPMC8879509 | biostudies-literature
Project description:Background and purposeCranial nerve palsies are regularly observed in patients with arteriovenous fistulas of the cavernous sinus. The purpose of our study was to determine the long-term clinical outcome-with a special focus on extra-ocular muscular dysfunctions-in patients who had undergone endovascular treatment of a cavernous sinus fistula with detachable coils.Materials and methodsSixteen patients were recalled for an ophthalmoneurologic control examination (mean interval of 4.4 years). The mRS and the EQ-5D questionnaire were used for the description of general outcome. Age, duration of symptoms, character of the fistula (direct, dural), and coil volume were tested to assess their relevance for persistent symptoms.ResultsAll patients displayed complete regression of chemosis, exophthalmus, and pulsating tinnitus with no evidence of recurrences. Oculomotor disturbances persisted in 9 of 13 patients and caused permanent diplopia in 7 patients. In 15 patients a mRS score of 1 or 2 was achieved; however, 7 patients reported some limitations in life quality (EQ-5D). A significant correlation was found between coil volume and persistent diplopia (P = .032) and persistent cranial nerve VI paresis (P = .037).ConclusionsCoil embolization of the cavernous sinus led to durable closure of AVF and reliable regression of acute symptoms. However, long-term follow-up showed a 44% rate of persistent cranial nerve deficits with disturbances of oculomotor and visual functions. This may be explained by the underlying fistula size itself and/or the space-occupying effect of the coils. As neuro-ophthalmologic outcome is crucial for control of therapeutic success, patients should be routinely examined by ophthalmologists.
| S-EPMC7965457 | biostudies-literature
Project description:Background and purposeThe published results of treating internal carotid artery aneurysms with the PED do not necessarily apply to its use in the posterior circulation because disabling brain stem infarcts can be caused by occlusion of a single perforator. In this multicenter study, we assessed the safety of PED placement in the posterior circulation.Materials and methodsA prospective case registry was maintained of all posterior circulation aneurysms treated with PEDs at 3 Australian neurointerventional centers during a 27-month period. The objective was to assess the complications and aneurysm occlusion rates associated with posterior circulation PEDs.ResultsThirty-two posterior circulation aneurysms were treated in 32 patients. No deaths or poor neurologic outcomes occurred. Perforator territory infarctions occurred in 3 (14%) of the 21 patients with basilar artery aneurysms, and in all 3, a single PED was used. Two asymptomatic intracranial hematomas were recorded. No aneurysm rupture or PED thrombosis was encountered. The overall rate of permanent neurologic complications was 9.4% (3/32); all 3 patients had very mild residual symptoms and a good clinical outcome. Aneurysm occlusion was demonstrated in 85% of patients with >6 months of follow-up and 96% of patients with >1 year of follow-up.ConclusionsThe PED is effective in the treatment of posterior circulation aneurysms that are otherwise difficult or impossible to treat with standard endovascular or surgical techniques, and its safety is similar to that of stent-assisted coiling techniques. A higher clinical perforator infarction rate may be associated with basilar artery PEDs relative to the internal carotid artery.
| S-EPMC7965498 | biostudies-literature
Project description:Background and purposeFlow diverters are increasingly used in the endovascular treatment of intracranial aneurysms. Our aim was to determine neurologic complication rates following Pipeline Embolization Device placement for intracranial aneurysm treatment in a real-world setting.Materials and methodsWe retrospectively evaluated all patients with intracranial aneurysms treated with the Pipeline Embolization Device between July 2008 and February 2013 in 17 centers worldwide. We defined 4 subgroups: internal carotid artery aneurysms of ≥10 mm, ICA aneurysms of <10 mm, other anterior circulation aneurysms, and posterior circulation aneurysms. Neurologic complications included spontaneous rupture, intracranial hemorrhage, ischemic stroke, permanent cranial neuropathy, and mortality. Comparisons were made with t tests or ANOVAs for continuous variables and the Pearson χ(2) or Fisher exact test for categoric variables.ResultsIn total, 793 patients with 906 aneurysms were included. The neurologic morbidity and mortality rate was 8.4% (67/793), highest in the posterior circulation group (16.4%, 9/55) and lowest in the ICA <10-mm group (4.8%, 14/294) (P = .01). The spontaneous rupture rate was 0.6% (5/793). The intracranial hemorrhage rate was 2.4% (19/793). Ischemic stroke rates were 4.7% (37/793), highest in patients with posterior circulation aneurysms (7.3%, 4/55) and lowest in the ICA <10-mm group (2.7%, 8/294) (P = .16). Neurologic mortality was 3.8% (30/793), highest in the posterior circulation group (10.9%, 6/55) and lowest in the anterior circulation ICA <10-mm group (1.4%, 4/294) (P < .01).ConclusionsAneurysm treatment with the Pipeline Embolization Device is associated with the lowest complication rates when used to treat small ICA aneurysms. Procedure-related morbidity and mortality are higher in the treatment of posterior circulation and giant aneurysms.
| S-EPMC7965920 | biostudies-literature
Project description:Intracranial dissecting aneurysms constitute rare lesions with complex management and elevated morbidity and mortality. Results of 23 patients harboring such lesions treated with the PED are reported. Standard dual antiplatelet therapy was instituted. Neurologic and angiographic assessments were obtained at 3, 6, and 12 months. Clinical presentation included SAH (52%), symptoms of mass effect (22%), ischemia (4%), and incidental finding (22%). The posterior circulation was affected in 91% of cases. Total occlusion was demonstrated in 69.5% of patients, with an increment to 87.5% considering only patients with at least 3 months of follow-up. Small aneurysms demonstrated higher rates of total occlusion (6/7) compared with large (5/7) and giant (5/9) ones. Good clinical outcome was achieved in 74% of patients. Reconstructive endovascular treatment of intracranial dissecting aneurysms with the PED provided good clinical and angiographic results with acceptable risks, representing an attractive therapeutic option for this complex disease, especially when parent vessel preservation is mandatory.
| S-EPMC7964407 | biostudies-literature
Project description:PURPOSE:Patient-reported long-term follow-up after endovascular treatment of indirect carotid cavernous fistulas is important, but rarely addressed in literature. We report on this issue with a special focus on the patient's view and its impact on the indication evaluation process. METHODS:We retrospectively reviewed the records of all patients (n = 33) with a minimum follow-up interval of at least 36 and up to 166 months after endovascular treatment of an indirect carotid cavernous fistula (Barrow B-D) at our institution (treated from 01/2003 to 06/2015). We determined treatment details including primary therapy success and complication rate and quote the patient's subjective perception of the long-term treatment success using a standardized interview form. RESULTS:As a primary result the fistula was completely occluded in 25/33 cases (76%), while a downgrading was achieved in 8/33 (24%) of the cases. Secondary occlusion was observed in three out of eight patients (38%). In the long-term interview (response rate: 91%, median follow-up interval: 114 months) 87% of the patients reported high satisfaction with the long-term therapy result. Endovascular treatment achieved a sustainable relief from all eye-related symptoms in 89% and from pulsatile tinnitus in 57% of the cases. CONCLUSIONS:In addition to good results in terms of angiographic and clinical cure, endovascular treatment is also perceived as beneficial by most of the patients. This is another important argument in favor of an endovascular treatment.
| S-EPMC7147764 | biostudies-literature
Project description:IntroductionThe detection of acquired arteriovenous fistulas (AVFs) is mostly incidental. However, the modification of haemodynamic conditions secondary to AVFs can lead to dramatic systemic complications, including cardiac complications. In this report, two unusual cases of congestive heart failure secondary to acquired AVF are presented.ReportA 40 year old man with past history of gunshot wound of the right flank complained of severe right limb swelling and shortness of breath. An AVF between the right external iliac artery and external iliac vein responsible for the cardiac failure was diagnosed. A 40 year old woman with past history of spinal surgery complained of breathlessness and lower limb oedema. She presented with recurrent episodes of ascites and dyspnoea. An AVF between the right common iliac artery and the common iliac vein responsible for high output cardiac failure was diagnosed. Open surgery was performed in both patients and treatment of the AVFs led to the resolution of all symptoms. Follow up at four and three years, respectively, was uneventful in both cases.DiscussionAlthough rare, heart failure secondary to an AVF can be encountered. These rare cases highlight the significance of careful inquiry into the patient's medical history and meticulous follow up physical examinations for patients with injuries in close proximity to vessels.
| S-EPMC8501500 | biostudies-literature
Project description:We report a clinical case of spontaneous bilateral carotid-cavernous fistulas. Bilateral pulsatile exophthalmos and symmetric cavernous sinuses detected by CT scan helped to suspect the diagnosis. Arteriography confirmed the diagnosis. The patient underwent embolization with favorable neurologic and ophthalmic evolution. Carotid-cavernous fistula is a rare but severe complication associated with a poor functional (blindness) and vital (meningeal and intracerebral hemorrhage) prognosis. The concomitant use of arteriography and embolization has considerably improved the prognosis.
| S-EPMC5554656 | biostudies-other
Project description:MethodThe clinical and imaging data of PEDs in the postmarket multicenter registry study (PLUS) in China were retrospectively analyzed, and patients were divided into two groups on the basis of the follow-up angiographic results: group 1 (no significant change in A1 blood flow) and group 2 (A1 occlusion or decreased blood flow). We collected patients' baseline data and evaluated the following imaging indicators: diameter and ratio of bilateral A1, M1, and internal carotid artery (ICA) vessels before stenting and the ratio of the PED size (sPED) to the ipsilateral ICA (I-ICA) diameter on the implantation side.ResultsA total of 1171 patients were included, of whom 48 met the inclusion criteria (17 in group 1 and 31 in group 2). In group 2, three patients experienced neurological deterioration at follow-up. From the univariate analysis of outcomes, single PED without coils, incomplete aneurysm occlusion (IAO), maximum aneurysm diameter, aneurysms involving the ICA bifurcation (ICAb), and large sPED/I-ICA diameter ratio were included in the multivariate analysis (P < 0.20). The multivariate regression analysis results showed that the ratio of sPED/I-ICA diameter was the factor influencing A1 vessel occlusion. The area under the ROC curve was 73.2%. When the sPED/I-ICA diameter ratio was 1.14, sensitivity was 70.6%, and specificity was 77.4%.ConclusionWhen an oversized PED is placed from M1 to the ICA, the higher porosity formed at the covered A1 orifice is conducive to maintaining stable A1 blood flow and reducing the risk of A1 vessel occlusion. This trial is registered with ClinicalTrials.gov identifier: NCT03831672.
| S-EPMC8405287 | biostudies-literature
Project description:BACKGROUND:Vascular Ehlers-Danlos syndrome (vEDS) is a rare condition characterized by connective tissue fragility. Direct spontaneous carotid-cavernous fistula (sCCF) is reportedly pathognomonic of vEDS. We conducted this study to understand the possible mechanisms of occurrence of sCCF in this subset of patients. METHODS:We conducted a retrospective analysis of a monocentric vEDS cohort along with a literature review regarding sCCF in this condition. RESULTS:Of 133 patients regularly followed in our centre between 2000 and 2017, 13 (9.8%) had a diagnosis of direct sCCF (92.3% female, median age 33.0 years, interquartile range (IQR) [26.0-39.5]). There were 7 Glycine missense and 6 splice-site variants but no variant leading to haploinsufficiency. The literature search identified 97 vEDS patients with direct sCCF (79.4% female, 7.2% sex not reported, median age 31.0 years, IQR [24.0-39.0]). Increased carotid circumferential wall stress, higher carotid distensibility and lower carotid intima-media thickness could contribute to a higher risk for direct sCCF in vEDS. There is no predictive factor for the occurrence of sCCF apart from female sex in vEDS. CONCLUSIONS:In vEDS, anatomical and pathophysiological features of the intra-cavernous internal carotid artery make it prone to shunting in the cavernous sinus, due either to a spontaneous rupture or to a spontaneous dissection with pseudoaneurysm formation. Direct sCCF in seemingly healthy young individuals should be highly suggestive of vEDS and prompt further investigation.
| S-EPMC6019721 | biostudies-literature