PMC3988606_01
40-year-old male accident victim with skull fracture presented with increasing left-sided proptosis which was diagnosed as carotid cavernous fistula due to rupture of intradural aneurysm. (a) Photograph of the patient's left eye shows proptosis and congestion. (b) T1-weighted magnetic resonance (MR) imaging done shows hyperintensity in the basal cisterns suggestive of subarachnoid hemorrhage (arrow). (c) Time of flight MR angiogram shows the fistulous communication on the left side (arrow).
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F1
On the 4th day of hospitalization, he developed increasing proptosis and conjunctival congestion [Figure 1a]. However, the precise location of the rent was not identified [Figure 1b and c].
Digital subtraction angiograms of left internal carotid artery in the (a) left oblique and (b) right oblique views show intradural aneurysm (white arrow) and the fistulous communication into the cavernous sinus and petrosal sinus (black arrows in a). (c) Road map image with stable position of the micro catheter achieved distally with gentle maneuver (arrow).
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F2
Digital subtraction angiogram of the left internal carotid artery showed intradural aneurysm (caused by the trauma), which was seen communicating inferiorly with cavernous sinus, basillar plexus, and petrosal sinus [Figure 2a and b]. A gentle steam shaping of the micro catheter tip was done to facilitate the navigation of the distal end of the micro catheter into the sinus [Figure 2c].
Post-coiling left internal carotid angiogram in (a) right oblique and (b) left oblique projections show complete occlusion of the aneurysm and the fistulous communication (arrows). (c) Townes view (arrow) shows the patent internal carotid artery with good flow in all the distal branches and no remnant fistula.
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F3
Post-coiling angiogram showed complete obliteration of the fistula and exclusion of the aneurysm from the circulation [Figure 3a-c].