Momoji J, Mukawa J, Yamashiro K, Kinjo T, Sakihara E, Harakuni T, Horikawa K
Department of Neurosurgery, Okinawa Prefectural Miyako Hospital, Japan.
No To Shinkei. 1997 Jan;49(1):85-91.
Two cases of direct carotid-cavernous fistula (CCF) were treated by transarterial platinum coil embolization (TACE) following unsuccessful transarterial balloon embolization (TABE). Case 1 was a 47-year-old man who complained of pulsatile left exophthalmos, chemosis and bruit. Left carotid angiograms showed a CCF with anterior, posterior and cortical venous drainage. Near total obliteration of the CCF was achieved by TABE, but it showed recurrence in the next morning. At this time, left carotid angiograms showed a CCF which drained only into the cortical veins via the enlarged sphenoparietal sinus. Because of high risk of intracranial hemorrhage, TACE was performed immediately. The result was successful. Case 2 was an 82-year-old woman who suffered from traumatic subarachnoid hemorrhage. First right carotid angiograms showed a small CCF which drained only into the inferior petrosal sinus. Right exophthalmos, swelling of the eyelids, severe eye pain and bruit appeared gradually. The second right CAG performed three months after the head trauma showed markedly dilated superior ophthalmic vein which was the new main draining root of the CCF. Because of progressive symptoms, TACE was performed immediately after the angiography, which proved successful. Direct CCFs must be treated aggressively because they don't cure by spontaneous obstruction of fistula. Although TABE is the first choice for direct CCF, complete occlusion of CCF in difficult in some cases. Those cases have; 1) small fistula of CCF for balloon insertion, 2) large fistula for occlusion by balloons, 3) not enough space for inserting a balloon after recurrence of CCF, and 4) sharp objects (bone fracture fragments, foreign objects) may puncture the balloon. If TABE couldn't provide successful treatments, TACE should be considered as an alternative treatment for direct CCF after angiography without delay because it is less complex compared with TABE.
两例直接型颈内动脉海绵窦瘘（CCF）患者在经动脉球囊栓塞术（TABE）失败后，接受了经动脉铂弹簧圈栓塞术（TACE）治疗。病例1为一名47岁男性，主诉左侧搏动性眼球突出、球结膜水肿和血管杂音。左侧颈动脉血管造影显示为CCF，伴有前、后及皮质静脉引流。TABE几乎完全闭塞了CCF，但次日出现复发。此时，左侧颈动脉血管造影显示CCF仅通过扩大的蝶顶窦引流至皮质静脉。由于颅内出血风险高，立即进行了TACE，结果成功。病例2为一名82岁女性，患有创伤性蛛网膜下腔出血。首次右侧颈动脉血管造影显示一个小的CCF，仅引流至岩下窦。右侧眼球突出、眼睑肿胀、严重眼痛和血管杂音逐渐出现。头部外伤后三个月进行的第二次右侧脑血管造影（CAG）显示眼上静脉明显扩张，这是CCF新的主要引流根。由于症状逐渐加重，血管造影后立即进行了TACE，结果成功。直接型CCF必须积极治疗，因为瘘口不会自行闭塞而治愈。虽然TABE是直接型CCF的首选治疗方法，但在某些情况下难以完全闭塞CCF。这些情况包括：1）CCF瘘口小，难以插入球囊；2）瘘口大，难以用球囊闭塞；3）CCF复发后没有足够空间插入球囊；4）尖锐物体（骨折碎片、异物）可能刺破球囊。如果TABE不能提供成功的治疗，应在血管造影后立即考虑将TACE作为直接型CCF的替代治疗方法，因为与TABE相比，它的操作不太复杂。
