PMC8879509_01
AP view (A) and lateral view (B) with direct fistula between cavernous segment of the right ICA and the cavernous sinus (green arrow). There is evidence of severe vasospasm in the intracranial vascular tree (red arrow). (C) Oblique view post partial coiling of the fistula site. (D) AP view and lateral view (E) of the right ICA post flow diverting stents and coiling with improvement of the CCF and improved flow intracranially.
fneur-12-715955-g0001.jpg
PMC8879509_01_fneur-12-715955-g0001.jpg
F1
The tCCF was embolized via a transvenous approach with a significant reduction of the fistulous flow (Figures 1A-C). Following a multidisciplinary discussion, a flow-diverting stent was deployed across the fistula in the cavernous segment with a subsequent significant reduction in arteriovenous shunting (Figures 1D,E).
PMC8879509_02
(A) Initial CTA with left cavernous pseudoaneurysm (red arrow). (B) first cerebral angiogram AP view and lateral view (C) showing the direct fistula between the cavernous segment of the left ICA and the left cavernous sinus at the site of ruptured pseudoaneurysm.
fneur-12-715955-g0002.jpg
PMC8879509_02_fneur-12-715955-g0002.jpg
F2
CTA of the head and neck was repeated revealing a new 4 mm pseudoaneurysm of the cavernous segment of the left internal carotid artery (Figure 2A). Conventional cerebral angiography revealed the presence of a high-flow left tCCF with angiographic evidence of compromised flow intracranially (Figures 2B,C).
Cerebral angiogram AP view (A) and lateral view (B) post flow diverter stenting at the site of the ruptured pseudoaneurysm with significant decrease of the flow in the fistula and improved perfusion to the brain.
fneur-12-715955-g0003.jpg
PMC8879509_02_fneur-12-715955-g0003.jpg
F3
Following deployment of the stent, improved flow to the left hemisphere was immediately noted (Figures 3A,B).
(A) Recurrence of the fistula post flow diversion stenting at the site of the ruptured pseudoaneurysm (red arrow). Notice the misplacement of the previously deployed stents (green arrow) secondary to the high flow of the CCF. Subtracted (B) and unsubtracted (C) views of the left ICA post sacrifice by means of coiling without any residual flow in the CCF. (D) Cerebral angiogram of the left vertebral artery post left ICA sacrifice AP view, showing adequate flow into the left middle cerebral artery through a large left posterior communicating artery (red arrow). (E) Head CT before discharge showing residual subdural hematoma with no signs of ischemic changes in the left hemisphere.
fneur-12-715955-g0004.jpg
PMC8879509_02_fneur-12-715955-g0004.jpg
F4
The patient passed the BTO and the left ICA was successfully embolized from the cavernous segment distally into the distal cervical segment proximally with no evidence of any flow into the carotid-cavernous fistula (Figures 4A-C). The patient's length of stay at the hospital was 27 days and he was discharged to an acute rehabilitation facility with no left hemispheric deficits (Figures 4D,E).