PMC9485939_01
(A) Lateral view of the left ICA angiography showing a CCF with dilated SOV (arrowhead). (B) Lateral view of the right VA angiography showing the retrograde blood flow (arrow) from a ruptured PPTA aneurysm (arrowhead), projecting into the left CS. (C) The optimal projection for PPTA emitting (arrowhead) from left ICA, the PPTA aneurysm (asterisk), and the distal orifice (arrow) of PPTA connecting to BA. (D) The fistula was confirmed by super-selective angiography. (E,F) Partial embolization of the fistula and the adjacent PPTA aneurysm exhibited the PPTA trajectory (arrow) more evident than untreated. (G,H) The fistula and aneurysm were completely embolized, while the CS and PPTA (arrow) were well-preserved. (I,J) Four-month follow-up angiography demonstrated complete obliteration of the fistula and PPTA aneurysm, while the preserved PPTA vanished. BA, Basal Artery; CCF, Carotid Cavernous Fistula; CS, Cavernous Sinus; ICA, Internal Carotid Artery; PPTA, Persistent Primitive Trigeminal Artery; SOV, Superior Ophthalmic Vein; VA, Vertebral Artery.
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Left ICA angiography revealed a left-sided CCF associated with a ruptured PPTA aneurysm, with major drainage to the ipsilateral SOV (Figure 1A). Vertebral angiography also revealed a retrograde blood flow of PPTA from BA to CS (Figure 1B). PPTA emitting from left ICA (Figure 1C), an Echelon-10 microcatheter (Medtronic-ev3, Minneapolis, MN, USA) guided by a Synchro2 microguidewire (Stryker, Salt Lake, Utah, USA) was directed into the PPTA aneurysm which was confirmed by super-selective angiography (Figure 1D). Partial embolization of fistula and proximal ruptured PPTA aneurysm exhibited the PPTA trajectory more obviously than untreated (Figures 1E,F). Finally, the fistula and aneurysm were completely embolized with four Axium detachable coils (Medtronic-PLC, Dublin, Ireland) followed by a 1.6 ml Onyx-18 liquid embolic system, while the CS and PPTA were well-preserved (Figures 1G,H). However, the preserved PPTA vanished (Figures 1I,J), but the patient had no neurological deficit.