Introduction: Iatrogenic Direct carotid-cavernous fistulas (CCFs) are uncommon complications of intracranial endovascular rescue. We describe the first reported case of an intraprocedural direct carotid cavernous fistula that developed immediately after flow restoration during treatment of an acute left M1 occlusion utilizing a Stent Retriever
Methods: This was an 86 year old right handed Caucasian woman who presented with acute onset of aphasia, right sided weakness, and right facial droop. The time of onset was unknown. NIHSS scale on arrival to the ED was 16. Stroke protocol CT Perfusion imaging demonstrated a large region of ischemic penumbra within the left MCA distribution. Occlusion of the left M1 segment with collaterals to a limited number of opercular, insular, and cortical branches was noted on CT Angiography. Successful TICI 3 endovascular rescue of the left M1 occlusion was obtained. Later attempts at embolizing the iatrogenic left CC Fistula were abandoned for patient safety.
Results: While CCFs are not life threatening, the morbidity from ocular complications can be high. Each Carotid Cavernous Fistula should be reviewed as a unique case and the optimal treatment should be selected to decrease risk to the patient.
Conclusions: Careful Endovascular navigation and device deployment of the retriever under full inspection of the roadmap may prevent or reduce the incidence of direct CCFs; however, sometimes it may become necessary to choose the potential complication to save a patient’s life as was the case described in this report.
Patient Care: We describe the first reported case of an intraprocedural direct carotid cavernous fistula that developed immediately after flow restoration during treatment of an acute left M1 occlusion utilizing a Stent Retriever
Learning Objectives: Iatrogenic direct CCFs secondary to vessel injury during endovascular rescue may be able to be observed rather than treated emergently unless they are associated with cortical venous reflux or hemodynamic compromise. Careful visualization of the underlying cavernous carotid artery and cautious navigation and device deployment under a high quality fluoroscopic roadmap may prevent or reduce the incidence of direct CCFs secondary to devices like stentrievers, however, ultimately the risk of proceeding must be weighed against the potential benefit, or in the case of an acute stroke secondary to a large vessel occlusion, the consequence of lack of success of revascularization.
References: 1. Korkmazer B, Kocak B, Tureci E, Islak C, Kocer N, Kizilkilic O. Endovascular treatment of carotid cavernous sinus fistula: A systematic review. World Journal of Radiology. 2013;5(4):143-155. doi:10.4329/wjr.v5.i4.143.
2. Gonzalez Castro LN, Colorado RA, Botelho AA, Freitag SK, Rabinov JD, SilvermanSB. Carotid-Cavernous Fistula: A Rare but Treatable Cause of Rapidly Progressive Vision Loss. Stroke. 2016 Aug;47(8):e207-9. doi: 10.1161/STROKEAHA.116.013428. Epub 2016 Jul 12. PubMed PMID: 27406104; PubMed Central PMCID: PMC5501979.
3. Gemmete JJ, Chaudhary N, Pandey A, Ansari S. Treatment of carotid cavernous fistulas. Curr Treat Options Neurol. 2010 Jan;12(1):43-53. doi:10.1007/s11940-009-0051-3. PubMed PMID: 20842489.
4. Rahman WT, Griauzde J, Chaudhary N, Pandey AS, Gemmete JJ, Chong ST.Neurovascular emergencies: imaging diagnosis and neurointerventional treatment. Emerg Radiol. 2017 Apr;24(2):183-193. doi: 10.1007/s10140-016-1450-x. Epub 2016 Oct 7. PubMed PMID: 27718098.