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|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 7 | Page : 115-116
Spontaneous carotid-trigeminal cavernous fistula obliterated using a combination of coils and onyx
Peng Liu, Xianli Lv, Youxiang Li, Ming Lv
Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China
|Date of Web Publication||3-Mar-2016|
Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Liu P, Lv X, Li Y, Lv M. Spontaneous carotid-trigeminal cavernous fistula obliterated using a combination of coils and onyx. Neurol India 2016;64, Suppl S1:115-6
We present the case of a 22-year-old woman with spontaneous carotid-trigeminal cavernous fistula (CTCF) accompanied by a persistent primitive trigeminal artery (PPTA) treated by a combination of coils and onyx [Figure 1]. Complete closure of the fistula was followed by resolution of the patient's symptoms. The one-year follow-up angiogram showed no recurrence of the lesion [Figure 2]. Our case highlights the fact that a combination of coils and onyx with the assistance of a micro-balloon may be used for the treatment of CTCF.
|Figure 1: Lateral views of right carotid and vertebrobasilar artery digital subtraction angiography (DSA; a and b). The right cavernous sinus is distended. Dilated superior ophthalmic vein and inferior petrosal sinus are visualized. After the inflation of a microballoon at the orifice, the lateral views of the right carotid and vertebrobasilar artery digital subtraction angiography showed that the fistula had disappeared (c - e). Postembolization right internal carotid and vertebrobasilar artery digital subtraction angiography showed that the fistula had completely occluded with the successful preservation of PPTA (f and g)|
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|Figure 2: 1 year after the surgery, the patient came back for DSA re - examination, which showed no recurrence of the PPTA fistula (a) and the preservation of PPTA was confirmed (b)|
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Spontaneous carotid-cavernous fistula (CCF), coexisting with a PPTA is a complex condition with an incidence rate of 0.1-0.6%.  To our knowledge, there are only 18 articles reporting 21 cases of spontaneous CTCF published in the English literature. Spontaneous CTCFs usually show a female predominance, and most cases involve a Saltzman type 2 PPTA, which is characterized by a well-formed mid-basilar artery (BA) and presence of posterior communicating arteries supplying the posterior circulation. Only one case reported by Charlin et al., was a type 3 variant with a hypoplastic basilar trunk. 
The congenital structural defects in the middle layer of the wall of the PPTA, as well as the concomitant hemodynamic stress, may result in the formation of the aneurysms as well as their rupture. The previous data has revealed that 7 of the 22 patients studied had a documented PPTA-associated aneurysm.  In our patient, the location of the fistula was corresponding with the location of the aneurysms in the studies reported in literature. The high-flow arteriovenous shunting might have obscured the underlying aneurysm in our case.
The treatment of CTCF had evolved from surgical ligation of the parent vessel to sophisticated endovascular treatments using balloons or coils via the transarterial, the transvenous, or the combined route. Onyx injection in combination with coils has been successfully been used in the treatment of spontaneous carotid cavernous fistula. , Coils are the ideal materials for carotid-cavernous fistulae closure; to completely occlude the orifice, however, a dense packing of the cavernous sinus might be required. The latter procedure might compress the cranial nerves in proximity to the cavernous sinus. The simultaneous use of onyx, a liquid embolic mixture significantly reduces the number of coils required to tightly pack the fistula. In addition, the simultaneous use of a balloon during the obliteration of the fistula helps in preserving the persistent trigeminal artery. Whether or not the PPTA has to be preserved in every case, remains a controversial issue. In the previous studies, most cases belonged to the type 2 fistula group, and out of the total number of cases reported, PPTAs were preserved in only12 cases. Ischemic stroke was only found in one case in whom an endovascular procedure was performed. The patient suffered from mild dysarthria and hemiparesis following the transvenous and transarterial coil embolization of the involved cavernous sinus and the PPTA, respectively.
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There are no conflicts of interest.
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. Diagnosis and management of trigemino-cavernous fistulas: Case report and review of the literature. J Neurointerv Surg 2015;7:73-8.
Charlin JF, Clavier E, Thiebot J, Brasseur G, Langlois J. Cavernous fistula caused by rupture of an aneurysm of the trigeminal artery: Case report. Rev Otoneuroophtalmol 1982;54:249-54.
Lv X, Jiang C, Li Y, Yang X, Wu Z. Percutaneous transvenous embolization of intracranial dural arteriovenous fistulae with detachable coils and/or in combination with Onyx. Interv Neuroradiol 2008;14:415-27.
Geibprasert S, Jiarakongmun P, Krings T, Pongpech S. Trigeminal fistula treated by combined transvenous and transarterial embolisation. Acta Neurochir (Wien) 2008;150:583-8.
[Figure 1], [Figure 2]