case_images: PMC9479571_01
case_images: Patient 1. (a-d) Sequential axial images of noncontrast cranial computed tomography scan reveal markedly enlarged the left sphenoparietal sinus and cortical veins along left cerebral hemisphere. There is some venous wall calcification.
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case_images: F1
case_images: There was some venous wall calcification [Figure 1].
case_images: Patient 1. Sequential (a-c) axial and (d) sagittal T2-weighted magnetic resonance images of the brain reveal markedly dilated left sphenoparietal sinus and cortical veins along left cerebral hemisphere. (e) Anteroposterior and (f) lateral views of magnetic resonance venographic images disclose multiple serpiginous engorged cortical veins in the left cerebral hemisphere.
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case_images: F2
case_images: Cranial magnetic resonance imaging, magnetic resonance angiography, and magnetic resonance venogram demonstrated left CCF with extensive cortical venous reflux [Figure 2].
case_images: Patient 1. Photograph of the patient's neck in lateral view shows the previous surgical scar (long vertical incision).
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case_images: F3
case_images: Physical examination revealed the previous surgical scar at the left side of her neck [Figure 3].
case_images: Patient 1. (a) Anteroposterior (AP) and (b) lateral views with (c, d) 3D rotational angiography of the left common carotid artery injection show no the existence of the external carotid artery, severe stenosis of the proximal internal carotid artery (ICA), and long segment of multiple small vascular channels, representing the recanalization of the left ICA through vasa vasorum, at the level of C3-C4. Previous surgical clip (arrow) is noted. AP views of the (e) left and (i) right ICAs injections and lateral views of (f) the left ICA and the left vertebral artery injections in (g) arterial and (h) venous phases demonstrate the left direct carotid-cavernous fistula (arrowheads) with retrograde drainage into markedly engorged sphenoparietal sinus and superficial middle cerebral veins. Following the occlusion of the left petrous ICA with coils, (j) AP and (k) lateral views of the left ICA injection reveal significant reduction of shunt flow. (l) AP view of unsubtracted image illustrates the entire coil mesh.
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case_images: F4
case_images: The previous surgical clip is noted [Figures 4a-d]. There was a direct high-flow fistula between the cavernous segment of the left ICA and the CS with retrograde venous drainage into markedly dilated left sphenoparietal sinus, superficial middle cerebral vein (SMCV), superior sagittal sinus through the vein of Trolard, and the left transverse sinus through the vein of Labbe [Figures 4e-i]. Subsequently, the microcatheter was advanced further into the petrous segment of the left ICA proximal to the fistula which was occluded with Axium Detachable coil (Medtronic, Minneapolis, Minnesota, USA) [Figures 4j-l].
case_images: Patient 1. Intraoperative photographs through the left pterional approach. (a) After durotomy. (b) Arterialized venous pouch. (c) Identifying the left optic nerve (ON). (d) Removal of the left anterior clinoid process. (e) Opening the dura over the ON. (f) Identifying the clinoidal segment of the left internal carotid artery (C5) under the ON. (g) Applying the fenestrated clip encircling the ON. (h) Before closing the dura. (i) axial view of cranial computed tomography bone window scan demonstrates the surgical clips.
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case_images: F5
case_images: ICA was clipped by the fenestrated clip encircling the left optic nerve [Figure 5]. In addition, the left ophthalmic artery (OA) was clipped by another clip.
case_images: Patient 1. (a) axial, (b) sagittal, and (c) coronal images of noncontrast cranial computed tomography scan, obtained 3 h after surgery, reveal abnormal hyperdensity within dilated cortical veins along left cerebral hemisphere, probably representing partially thrombosis of the cerebral veins.
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case_images: F6
case_images: Cranial CT scan was obtained immediately and demonstrated abnormal hyper hyperdensity within dilated cortical veins along left cerebral hemisphere, probably representing partially thrombosis of the cerebral veins [Figure 6].
case_images: Patient 1. Cerebral angiography obtained 1 month after surgery. (a-d) Anteroposterior (AP) and lateral views of the left common carotid artery injection reveals the remaining of severe stenosis of the proximal internal carotid artery (ICA) with associated vasa vasorum and reduction in shunt flow and size of the dilated draining vein along the left cerebral hemisphere. (e) AP view of the right ICA injection demonstrates the clival branch (arrowhead) from the right meningohypophyseal trunk supplying the fistula. AP views of the (f) right and (g) left vertebral arteries (VAs) and (h) lateral view of the left VA injections show the reconstitution from the muscular branch (arrows) of the left VA feeding the fistula. After embolization with coils at the fistulous part, (i) AP and (j) lateral views of the left CCA and (k) AP and (l) lateral views of the left VA confirm nearly complete obliteration of the fistula.
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case_images: F7
case_images: ICA with associated vasa vasorum and reduction in shunt flow and size of the dilated draining vein along the left cerebral hemisphere [Figures 7a-d]. In addition, the fistula received additional supply from the contralateral ICA and left VA [Figures 7e-h]. Post embolization angiography showed nearly obliteration of the fistula [Figures 7i-l].
case_images: Patient 1. (a) axial, (b) sagittal, and (c) coronal images of noncontrast cranial computed tomography scan, obtained 5 days after second embolization with coils, reveal abnormal hyperdensity within dilated cortical veins along left cerebral hemisphere, probably representing ongoing venous thrombosis.
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case_images: F8
case_images: Cranial CT scan, obtained 5 days after the second embolization, revealed abnormal diffuse hyperdensity within the left sphenoparietal sinus, SMCV, the vein of Trolard, and the vein of Labbe, probably representing ongoing venous thrombosis [Figure 8].
case_images: Patient 1. Cerebral angiography obtained 1 year after the second embolization. (a) Anteroposterior (AP) and (b) lateral views of the left common carotid artery, (c) AP view of the right internal carotid artery, (d) AP view of the right external carotid artery, and (e) AP and (f) lateral views of the left vertebral artery injections confirm no recurrence of the fistula.
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case_images: F9
case_images: Follow-up cerebral angiography, obtained 1 year after the second embolization, confirmed no recurrence of the fistula [Figure 9].
case_images: Patient 1. Cranial computed tomography scan obtained 9 years after treatments. (a-f) Sequential axial images of noncontrast cranial computed tomography scan reveal encephalomalacia of the left cerebral hemisphere with multiple scattered ring calcifications.
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case_images: F10
case_images: Final cranial CT scan revealed encephalomalacia of the left cerebral hemisphere with multiple scattered ring calcifications [Figure 10].
case_images: PMC9479571_02
case_images: Patient 2. (a) Axial, (b) sagittal, and (c) coronal images of contrasted cranial computed tomography scan reveal skull base fracture, the dilatation of the right ophthalmic vein, and a large pseudoaneurysm (arrowhead) within the sphenoid sinus. (d) Anterolateral (AP) and (e) lateral views of the right internal carotid artery (ICA) show direct high-flow carotid-cavernous fistula with a large pseudoaneurysm (arrowhead). (f) Lateral view of the right external carotid artery demonstrates retrograde flow through the right ophthalmic artery (asterisk) through meningo-ophthalmic artery anastomosis, supplying the fistula. (g) AP view of the left ICA injection discloses the clival branch from the left meningohypophyseal trunk supplying the fistula. (h) AP and (i) lateral views of the left vertebral artery illustrate the fistulous point (arrow) between the clinoidal segment of the right ICA and cavernous sinus.
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case_images: F11
case_images: The CT scan showed fractures at right-sided planum sphenoidale and superior wall of the sphenoid sinus, enlarged right superior ophthalmic vein (SOV), dilatation of bilateral CS, and large pseudoaneurysm within sphenoid sinus [Figures 11a-c]. The subsequent venous drainages from the left CS ran anteriorly into the left SOV, and posteroinferiorly into the left IPS [Figures 11d-e]. The right ECA injection demonstrated retrograde flow through the right OA through meningo-OA anastomosis, supplying the fistula [Figure 11f]. Willis with patent ACoA and right PCoA to right hemisphere [Figures 11g-i]. We decided to treat this patient using sacrifice the right ICA.
case_images: Patient 2. (a) Anteroposterior and (b) lateral views of the right common carotid artery confirm complete occlusion of the right carotid artery after the occlusion of detachable balloons with intradural internal carotid artery opacification through retrograde filling of the right meningo-ophthalmic artery anastomosis.
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case_images: F12
case_images: The right CCA injection confirmed complete occlusion of the right ICA with intradural ICA opacification through retrograde filling of the right meningo-OA anastomosis [Figure 12].
case_images: Patient 2. Intraoperative photographs through the right pterional approach. (a, b) Identifying the right optic nerve (ON) and the ophthalmic segment of the right internal carotid artery (C6). After clipping the C6, illustrating the right arterialized Sylvian veins (c) before and (d) after placing the clip.
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case_images: F13
case_images: The right optic nerve and the ophthalmic segment of the right ICA were identified under microscope [Figures 13a and b]. After clipping the right supraclinoid ICA, the right arterialized sylvian veins changed in color from arterialized reddish color to purple [Figures 13c and d].
case_images: Patient 2. (a) Axial view of cranial computed tomography (CT) bone window scan demonstrates the surgical clip near the right anterior clinoid process. Sagittal maximum intensity projection reformatted images of angiographic CT (b) before and (c) after surgery reveal the disappearance of the pseudoaneurysm within the sphenoid sinus. Lateral views of (d) arterial and (e) venous phases of the right external carotid artery injection reveal the residual fistula fed by the right ophthalmic artery (asterisk) reconstituted from the right middle meningeal artery. (f) AP view of the left internal carotid artery injection demonstrates the clival branch (arrow) from the left meningohypophyseal trunk supplying the fistula. (g) AP and (h) lateral views of the left vertebral artery injection show good collateral supply of the right cerebral hemisphere from the vertebrobasilar system via the right posterior communicating artery. (i) Lateral view of unsubtracted image illustrates the entire coil mesh after embolization.
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case_images: F14
case_images: Transvenous embolization was subsequently carried out through the right IPS using fibered interlocking detachable coils (Interlock-35, Boston Scientific, Natick, MA) densely packing in the proximal right SOV and within the CS [Figure 14].
case_images: Patient 2. Cerebral angiography obtained 1 year after the second embolization. (a) Anteroposterior and (b) lateral views of the right common carotid artery, and (c) anteroposterior view of the left internal carotid artery injections confirm no recurrence of the fistula.
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case_images: F15
case_images: Cerebral angiography, obtained 1 year after the second embolization, confirmed no recurrence of the fistula [Figure 15].
case_images: PMC9479571_03