Spontaneous direct carotid-cavernous sinus fistula secondary to a persistent primitive trigeminal artery treated by trans-venous coil embolisation

Abstract

<jats:p> A healthy 51-year-old female presented with a spontaneous direct carotid-cavernous sinus fistula associated with a persistent primitive trigeminal artery. She had no history of connective tissue or cerebrovascular disorders or significant head trauma. This is a rare lesion with only 18 previously reported cases. It had similar clinical presentation and imaging appearance to a high-flow direct carotid-cavernous fistula and was uncovered after successful trans-venous coil embolisation of the fistula. It therefore needs to be considered in cases of direct carotid-cavernous fistula without history of trauma. Knowledge of types of persistent primitive trigeminal artery is also important for their critical treatment implications. </jats:p>

Case report: Spontaneous carotid-cavernous fistula associated with persistent primitive trigeminal artery aneurysm rupture

“…In 2018, Imrie et al treated a spontaneous CCF secondary to a ruptured PPTA aneurysm with detachable coils in the CS through the inferior petrosal sinus (IPS). Eventually, the CS was completely occluded and the fistula vanished ( 20 ). In 2000, Oka et al also used detachable coils to treat a similar CCF through the right IPS approach.…”

Endovascular electrothrombosis treatment for carotid cavernous fistula caused by ruptured primitive trigeminal artery aneurysm: a case report and literature review

“…Initially, detachable balloon occlusion was the treatment of choice [18] . However, the convoluted nature of vascular ow and pathways may at times impede balloon navigation through the stula into the cavernous sinus [20,21] , posing a risk of recurrence. Among the reviewed cases, a mere two instances of successful detachable balloon occlusion with positive prognoses are reported.Liu and associates were the pioneers in documenting the employment of detachable coils for the resolution of CCF secondary to ruptured PPTA aneurysms, with bene cial results [22] .…”

Clinical Importance of the Persistent Primitive Trigeminal Artery in Vascular Lesions and Its Role in Endovascular Treatment

“…For TCFs of Saltzman type I PPTAs with a hypoplastic vertebrobasilar system or Saltzman type III PPTAs, the PPTA should be preserved ( 50 , 52 ). During EVT, intra-aneurysmal coiling for treating TCF while preserving the PPTA is not difficult because the aneurysm may have a narrow neck ( 53 ). Sometimes, balloon or stent-assisted coiling can be used ( 30 ).…”

“…For TCFs without aneurysm necks or with tortuous PPTA, a transvenous approach via an accessible inferior petrosal sinus route may be suitable ( 53 ). Because transvenous packing of the CS requires a large volume of coils, ocular symptom exacerbation and venous infarction may occur, but these can usually be avoided by coiling the venous pouch of the TCF ( 30 ).…”