CTA-guided outflow-targeted embolization of direct carotid-cavernous fistula

Chih-Hsiang Liao, MD,1,2 Wen-Hsien Chen, MD,4 Nien-Chen Liao, MD,3 and Yuang-Seng Tsuei, MD1,2,5 1Chung Shan Medical University, Institute of Medicine, Taichung; Departments of 2Neurosurgery and 3Neurology, Neurological Institute, and 4Department of Neuroradiology, Taichung Veterans General Hospital, Taichung; and 5Department of Neurosurgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan This video presents a case of new-onset visual blurring, diplopia, and conjunctival injection after head injury. CTA of the brain revealed a direct carotid-cavernous fistula (dCCF) of the right side. Careful evaluation of CTA source images revealed that the fistula point was at the ventromedial aspect of the right cavernous internal carotid artery (ICA), about 3.6 × 3.6 mm2 in size, with 3 main outflow channels (2 intracranial and 1 extracranial) (CTA-guided concept). DSA of the brain also confirmed the diagnosis but was unable to locate the fistula point in a large-sized dCCF. Through a transfemoral artery approach, 3 microcatheters were navigated to each peripheral channel to initiate outflow-targeted embolization. Intracranial refluxes were blocked first to avoid cerebral hemorrhages, followed by the extracranial outflow. During embolization, accidental dislodge of one coil into the sphenoparietal vein occurred, but no attempt of coil retrieval was made. Complete obliteration of the dCCF was achieved, and the patient recovered well without new neurological deficits. 4D MRA at the 3-month follow-up showed no residual dCCF.