Endovascular Coil Occlusion of Traumatic Intradural Aneurysm with Presentation as Carotid Cavernous Fistula
A 40-year-old man presented to the emergency room following a road traffic accident. Computed tomography scan of the brain (plain) revealed frontal hematoma, intraventricular hemorrhage, and subarachnoid hemorrhage with depressed skull fracture. Emergency craniotomy with decompression was performed. On the 4th day of hospitalization, he developed increasing proptosis and conjunctival congestion []. Magnetic resonance (MR) imaging showed hyperintense signals in the basal cisterns suggestive of subarachnoid hemorrhage on T1-weighted sequence. Time of flight MR angiogram maximum intensity projection image showed abnormal communication between internal carotid artery and cavernous sinus. However, the precise location of the rent was not identified [Figure and ]. Digital subtraction angiogram of the left internal carotid artery showed intradural aneurysm (caused by the trauma), which was seen communicating inferiorly with cavernous sinus, basillar plexus, and petrosal sinus [Figure and ]. There was severe vasospasm seen in all the cerebral vessels. Endovascular treatment was planned in order to occlude the aneurysm and the fistulous communication. Balloon occlusion test was not tolerated and hence we chose to occlude the aneurysm and the fistulous communication (preserving the parent artery) over parent vessel occlusion.\nUnder general anesthesia, 6 French guiding catheter was placed in the left internal carotid artery. Echelon micro catheter with traxcess microwire was inserted into the aneurysm. A gentle steam shaping of the micro catheter tip was done to facilitate the navigation of the distal end of the micro catheter into the sinus []. Selective micro-catheter angiogram showed high flow through the aneurysm into the cavernous sinus and inferior petrosal sinus. After achieving stable position of the micro-catheter distally, multiple platinum detachable coils were placed occluding the flow into the sinus. Thereafter, the aneurysm was completely packed with multiple coils and complete occlusion was achieved with no flow into the fistulous communication. Post-coiling angiogram showed complete obliteration of the fistula and exclusion of the aneurysm from the circulation [Figure –]. Patient's proptosis and congestion dramatically decreased over the next few days. Long-term follow-up to assess the coil compaction and recanalization is waiting to be done.