Endovascular treatment options for carotid-cavernous fistulae

A carotid-cavernous fistula is a pathological shunt between the internal or external carotid arteries and the cavernous sinus (CS). The arteriovenous shunt can be direct, between the internal carotid artery and the CS, or indirect, between meningeal branches from the carotid arteries and the dural coverings of the CS. Direct fistulas occur most commonly after craniofacial trauma, while indirect shunts result from various chronic diseases. Signs and symptoms depend on the venous drainage routes. Exophthalmos, chemosis, and diplopia are caused by venous drainage through the superior and inferior ophthalmic veins. If venous egress is mainly through the inferior petrosal sinus, patients complain of pulsatile tinnitus. Cortical venous drainage is the most dangerous route because it can lead to focal neurological deficits and intracerebral haemorrhage. Treatment of carotid-cavernous fistulae can be achieved through different endovascular techniques, using detachable balloons, coils, liquid embolic agents, covered stents, and flow-diverters. This paper aims to report three cases with carotid-cavernous fistulae, which were successfully cured using different transarterial and transvenous modalities

Endovascular treatment options for carotid-cavernous fistulae

A carotid-cavernous fistula is a pathological shunt between the internal or external carotid arteries and the cavernous sinus (CS). The arteriovenous shunt can be direct, between the internal carotid artery and the CS, or indirect, between meningeal branches from the carotid arteries and the dural coverings of the CS. Direct fistulas occur most commonly after craniofacial trauma, while indirect shunts result from various chronic diseases. Signs and symptoms depend on the venous drainage routes. Exophthalmos, chemosis, and diplopia are caused by venous drainage through the superior and inferior ophthalmic veins. If venous egress is mainly through the inferior petrosal sinus, patients complain of pulsatile tinnitus. Cortical venous drainage is the most dangerous route because it can lead to focal neurological deficits and intracerebral haemorrhage. Treatment of carotid-cavernous fistulae can be achieved through different endovascular techniques, using detachable balloons, coils, liquid embolic agents, covered stents, and flow-diverters. This paper aims to report three cases with carotid-cavernous fistulae, which were successfully cured using different transarterial and transvenous modalities

The Removal of a Fractured Guidewire During Mechanical Thrombectomy. A Case Report

Recent randomized controlled trials have transformed the treatment of acute ischemic stroke. Mechanical or aspiration thrombectomy is the main treatment option for occlusions of large intracranial vessels. Despite its high technical success rate, endovascular thrombectomy can sometimes be complicated by anatomical peculiarities or device failures. The most frequent complications are related to vessel dissection or vessel perforation by devices while navigating intricate anatomy. Rarer still are technical device failures, like spontaneous stent-retriever detachment, which occurred with older generation retrievers. This case reports a rare device failure, which, to the best of our knowledge, has not been reported in the literature so far, namely a microwire fracture in the middle cerebral artery. This was successfully removed with an Eric stent-retriever. The potential causes and possible management strategies are discussed

Single-session treatment of bilateral, tandem, internal carotid artery aneurysms with pipeline flex with shield technology

The treatment of intracranial aneurysms (IA) has been transformed by the development of flow-diversion (FD) devices. Initially, these revolutionary devices were conceived for giant and fusiform aneurysms located on the internal carotid artery (ICA). Technological improvements have expanded their indications. Distal middle cerebral, anterior cerebral artery aneurysms, or even posterior fossa aneurysms can now benefit from this technology. One other category of aneurysms that can be treated is multiple IA’s. Multiple IA’s are encountered in approximately one-quarter of patients presenting with subarachnoid haemorrhage. Endovascular management of such cases is complex, requiring different devices and treatment strategies to secure all lesions. FD’s can be successfully employed to reconstruct vessels, which harbour more than one aneurysm, especially multiple ICA lesions. Multiple aneurysms located on both ICA’s are generically known as tandem aneurysms. We present the case of a patient with tandem aneurysms located on both intracranial internal carotid arteries that we treated simultaneously with the Pipeline Flex with Shield Technology in one single session. To the best of our knowledge, this is the first case reported in the literature so far

Postpartum Acute Basilar Artery Occlusion Secondary to Vertebral Artery Dissection. Case Report and Literature Review

Female patients in the peripartum and postpartum periods have an increased risk of stroke than nonpregnant women. Cerebrovascular complications of pregnancy represent a significant cause of maternal mortality and morbidity and are potentially disabling. Acute basilar artery occlusion secondary to spontaneous vertebral artery dissection in the postpartum period is an infrequent entity and a major diagnostic and treatment challenge. In the present case, a 37-year-old female patient, eight weeks after caesarean delivery, presented with a history of sudden cervical pain, followed by headache and dizziness. Some hours later, she was found unconscious by her family and was transferred to the emergency department, where a neurological status assessment suggested vertebrobasilar stroke. The imagistic workup revealed right vertebral artery dissection and basilar artery occlusion without constituted ischemic lesions. The patient underwent endovascular intervention with dilation of the narrowed vertebral artery and stent retriever basilar artery thrombectomy, with a favourable clinical outcome. This report first presents the details of this case and the relevant literature data on postpartum arterial dissections and the subsequent ischemic complications and available treatment options

Textural Analysis of the Hyperdense Artery Sign in Patients with Acute Ischemic Stroke Predicts the Outcome of Thrombectomy

Textural analysis is pivotal in augmenting the diagnosis and outcomes of endovascular procedures for stroke patients. Due to the detection of changes imperceptible to the human eye, this type of analysis can potentially aid in deciding the optimal type of endovascular treatment. We included 40 patients who suffered from acute ischemic stroke caused by large vessel occlusion, and calculated 130 different textural features based on the non-enhanced CT scan using an open-source software (3D Slicer). Using chi-squared and Mann–Whitney tests and receiver operating characteristics analysis, we identified a total of 21 different textural parameters capable of predicting the outcome of thrombectomy (quantified as the mTICI score), with variable sensitivity (50–97.9%) and specificity (64.6–99.4%) rates. In conclusion, CT-based radiomics features are potential factors that can predict the outcome of thrombectomy in patients suffering from acute ischemic stroke, aiding in the decision between aspiration, mechanical, or combined thrombectomy procedure