Türk Nöroşirürji Dergisi 2022 , Vol 32 , Num 1
A Rare Case: Endovascular Management of Multiple Internal Carotid Artery Aneurysms and Spontaneous Carotid-Cavernous Fistula Coexistence
Carotid-cavernous fistulas (CCF) are pathological connections between the internal carotid artery (ICA) and the cavernous sinus. CCFs may develop spontaneously (idiopathic) or secondary to the rupture of the ICA or its branches. Spontaneous CCFs are rare and are generally known as Barrow type D indirect fistulas. Almost all of the CCF - aneurysm coexistences in the literature include fistulas secondary to rupture of an ICA cavernous segment aneurysm. In this study, we present a complex case that two saccular aneurysms of the ICA ophthalmic segment were found with spontaneous indirect (Barrow type B) CCF, which has no example in the literature. A 49-year-old female patient with no previous history of subarachnoid hemorrhage was admitted to our clinic with pulsatile proptosis, chemosis, and near-complete vision loss. Digital subtraction angiography showed two aneurysms in the right ICA ophthalmic segment and indirect CCF in the right cavernous sinus in the late arterial phase. First of all, the aneurysms were treated by using flow diverter and coil embolization, in order to eliminate the risk of rupture. In the following sixth months, after it was ensured that the aneurysms were secured, flow diverter was placed in the cavernous segment of the ICA to cover the fistula to treat CCF. At the control of the second week after the treatment, proptosis and chemosis were significantly improved and there was partial recovery in vision. The control angiography of the third month of CCF treatment was observed that the anterograde pathological filling in the fistula and the superior ophthalmic vein decreased almost completely and there was no filling in the aneurysms. We did not encounter any complications or clinical worsening in the two-year followup of that patient. In conclusion, spontaneous CCFs can be seen together with cerebral aneurysms and endovascular flow diverting stents should be kept in mind as a good treatment option in the management of these complex cases. This report is the first example in the literature of the coexistence of spontaneous indirect CSF and multiple cerebral aneurysms. Anahtar Kelimeler : Carotid-cavernous sinus fistula, Cerebral aneurysm, Endovascular procedures