{"\ufeff\nJournal of Cardiovascular, Neurovascular & Stroke \nhttps://mycvns.com \nCASE REPORT: SUCCESSFUL STAGED EMBOLIZATION OF A \nDIRECT CAROTID-CA VERNOUS FISTULA USING COMBINED \nCOIL AND LIQUID EMBOLIC TECHNIQUE \nAnantika Putri1, Krisna Ayu1, Ahmad Sobri Muda2*, Mohd Hanif Bin Amran2,3, \nAnas Tharek2, Mohd Fandi Al Khafiz Kamis2, Stephen Mah Sin Yeat2,4\n1Department of Radiology, Universitas Brawijaya Malang, Indonesia \n2Department of Radiology, Hospital Pengajar Universiti Putra Malaysia, Selangor, Malaysia \n3Department of Radiology, Avisena Specialist Hospital, Selangor, Malaysia \n4Department of Radiology, Pantai Hospital Ayer Keroh, Melaka, Malaysia \n*Corresponding author: \nAhmad Sobri Muda, Department of Radiology, Hospital Pengajar Universiti Putra Malaysia, \nSelangor, Malaysia \nEmail:\nDOI: 6/cvns.v7n1.19-27 \nReceived: 09.03.2024 \nRevised: 28.03.2025 \nAccepted: 29.03.2024 \nPublished: 31.03.2024 \nABSTRACT \nCarotid-cavernous fistulae (CCFs) are a common complication after head trauma, accounting for 75% of all cases. They typically present with proptosis, ocular bruit, and chemosis, known as the classical triad. However, other symptoms may occur depending on the involvement of vascular and neural structures in the cavernous sinus. Digital Subtraction Angiography (DSA) is the gold standard for diagnosing CCFs. Traditionally, treatment involved open surgical procedures such as carotid ligation, trapping, and cavernous sinus exploration. Other options include conservative management and radiosurgery. In recent years, endovascular treatment (EVT) has become the preferred approach. Both transarterial and transvenous embolization using various agents aim to completely close the fistula while preserving carotid artery flow. This report presents the successful management of a right direct CCF in a 47-year-old male following a motor vehicle accident (MVA). A staged embolization approach, combining transvenous and transarterial techniques, effectively reduced the residual fistula without immediate complications. This case highlights the complexities of post-traumatic CCF treatment and the importance of tailored endovascular strategies. \nKeywords: Neurointerventional surgery, carotid-cavernous fistula, digital subtraction angiography, endovascular procedure, therapeutic embolization\n19 \n\nJournal of Cardiovascular, Neurovascular & Stroke \nhttps://mycvns.com \nINTRODUCTION: \nCarotid-cavernous fistulae (CCFs) are \ndeflation, or detachment may occur. Transvenous embolization is used for \nabnormal\narteriovenous\nconnections\nindirect fistulas or cases where transarterial\n\nbetween the carotid arterial system and the cavernous sinus, often resulting from head trauma. These fistulas can cause increased venous pressure, leading to significant \naccess is challenging. Studies report a 70\u201390% success rate with this approach [1]. \nThis case report presents the successful \nmanagement of a post-traumatic direct CCF \nophthalmological \tand \tneurological in a 47-year-old male following a motor \nsymptoms such as proptosis, chemosis, vehicle accident. A staged embolization \nelevated \tintraocular \tpressure, \tvision approach \tcombining \ttransvenous \tand \nimpairment, and cranial nerve dysfunction. Symptoms vary depending on the severity of the fistula and its impact on vascular and neural structures [1-6]. CCFs are classified \ntransarterial techniques was performed, leading to significant reduction of the fistula without immediate complications. This case highlights the complexities of \nbased on the Barrow classification. Type A\nCCF\ntreatment\nand\nemphasizes\nthe\n(Direct CCF) is a direct connection between\nimportance\nof\ntailored\nendovascular\n\nthe internal carotid artery (ICA) and the cavernous sinus, often caused by trauma. Types B-D (Indirect CCFs) involve branches of the internal or external carotid artery and are usually spontaneous or due to underlying vascular abnormalities [7-9]. \nstrategies based on individual patient anatomy and fistula characteristics. \nCASE REPORT: \nA 47-year-old male was involved in a motor \nvehicle accident (MVA) in September \nDiagnostic\napproach\ninvolving\nthe\n2024. 4 days later, he developed vision loss\n\nnoninvasive imaging methods, such as CT, MRI, and CT/MR angiography, can help identify cavernous sinus enlargement, superior ophthalmic vein dilation, and extraocular muscle swelling, which are suggestive of CCF. However, digital subtraction angiography (DSA) remains the gold standard for definitive diagnosis and \ntreatment\nplanning\n[5].\nManagement\nstrategies\ninvolving\nthe\nendovascular\ntreatment (EVT) has become the first-line approach due to its minimally invasive nature and high success rates. The goal is to completely occlude the fistula while preserving carotid artery function. Mild or low-risk CCFs may resolve spontaneously. Urgent intervention is needed for cases with pseudoaneurysms, large venous varices, cortical venous drainage, or venous thrombosis, which increase the risk of hemorrhage or neurological deterioration. Two primary endovascular techniques are \nin his right eye, proptosis, conjunctival chemosis, elevated intraocular pressure, absence of eye movement, and pulsatile tinnitus on the right side. Initial imaging suggested a right carotid-cavernous fistula with acute intraparenchymal hemorrhage in the right cerebellum (Figure 1). He also sustained fractures of the right sphenoid and petrous part of the right temporal bone. One week after his MVA, an initial coil embolization procedure was performed using both transvenous and transarterial access. Seven fibered coils were deployed into the venous sac of the cavernous sinus, resulting in partial occlusion of the CCF. An attempt to use a detachable silicone balloon was unsuccessful due to the small orifice of the fistula. A post-procedure angiogram showed only minimal reduction in CCF flow (Figure 2). After more than six hours, the procedure was stopped, and a staged embolization approach was planned. Staged \ncommonly used. Transarterial embolization\nembolization\ninvolves\nperforming\n\nis preferred for direct, high-flow CCFs, often using detachable balloons or other embolic agents. However, complications \nembolization in multiple sessions rather than all at once. This approach helps maintain normal blood circulation, allows \nsuch\nas\nballoon\nrupture,\npremature\nthe body to gradually adapt, and minimizes\n20 \n\nJournal of Cardiovascular, Neurovascular & Stroke \nhttps://mycvns.com \ncomplications. However, there was no significant improvement, as the patient continued to experience symptoms. \nA second embolization was performed 2 weeks after MVA, employing a more aggressive and multifaceted approach. One fibered coil was deployed into the right cavernous sinus, followed by the injection of 1 ml of Precipitating Hydrophobic Injectable Liquid (PHIL) 30%. An Eclipse 2L balloon catheter was inflated at the fistula point of the right ICA to prevent reflux into the parent artery. This procedure was repeated several times until satisfactory occlusion was achieved. Post-procedure angiogram showed significant reduction of the CCF flow, with only approximately 20% residual flow remaining. After five months, MRA showed complete resolution of the CCF. Vertigo, right ear ringing, right \nbeyond the venous sac of the fistulae. This approach aligns with current trends in \nneurointerventional\npractice,\nwhere\ncombinations of embolic materials are used to achieve optimal results. The staged embolization effectively decreased fistula flow while preserving adjacent vascular structures, demonstrating the value of adaptable treatment strategies. In cases with small fistula orifices and complex venous drainage patterns, achieving complete occlusion in a single session may not always be feasible. \nThe incorporation of PHIL, a relatively new liquid embolic agent, in the second procedure is noteworthy. PHIL offers several advantages, including reduced artifacts on follow-up imaging and a cohesive nature that minimizes the risk of distal embolization. Its use in this case, \neye bulging has already resolved and right combined \twith \tballoon \tprotection, \neyelid \tdrooping \timproved. \tPatient exemplifies the ongoing evolution of \nambulating well without assistance and able to drive again. \nDISCUSSION: \nThis case exemplifies the complexities involved in managing direct post-traumatic CCFs and highlights several key points in their treatment. Traumatic CCFs constitute the majority of direct CCFs, accounting for approximately 87.24% of cases [4]. The patient's presentation with classic signs of orbital venous congestion is typical for \nembolic techniques in neurointerventional procedures. PHIL's unique properties make \nit\nparticularly\nsuitable\nfor\nCCF\nembolization. Its non-adhesive nature allows for more controlled delivery, while its precipitating mechanism provides rapid and stable occlusion. The tantalum-based radiopaque component offers excellent visibility during injection, enabling precise placement and reducing the risk of non-target embolization. \nWhile multiple embolization procedures \nhigh-flow direct\nCCFs. Endovascular\ncan\nbe\nphysically\nand\nemotionally\nembolization has become the gold standard\nchallenging,\npatient\naccept\nthem\nas\n\nin CCF management. The combination of transvenous and transarterial techniques, as employed in this case, offers enhanced control over embolic materials and reduces procedural risks. \nThe second procedure demonstrates the \nnecessary for better long-term results. Clear communication with the medical team, psychological support, and reassurance about the safety and benefits of staged embolization can help ease their concerns. While staged embolization improves safety \neffectiveness of a multi-modal approach in\nand\ntreatment\nsuccess,\nit\nincreases\nchallenging cases. The use of PHIL 30% as\nhospitalization\nduration\nand\nfinancial\na liquid embolic agent, in conjunction with\nstrain.\nPatients\nmay\nneed\nfinancial\n\nfibered\ncoils\nand\nballoon-assisted\ntechniques, provided precise control and minimized the risk of embolic migration [7]. PHIL 30% has higher viscosity enable more control and less risk of penetration \n21 \n\nJournal of Cardiovascular, Neurovascular & Stroke \nhttps://mycvns.com \nCONCLUSION: \nThis case report illustrates the successful management of a complex, post-traumatic direct CCF through a staged endovascular approach. The combination of transvenous and transarterial techniques, along with the use of both traditional (coils) and novel (PHIL) embolic agents, proved effective in significantly reducing fistula flow. This \ncase\nunderscores\nthe\nimportance\nof\nindividualized treatment planning in CCF management. It highlights the value of a flexible approach, where initial incomplete \nresults\ncan\nbe\naddressed\nthrough\nsubsequent, more aggressive interventions. The use of cutting-edge embolic agents like PHIL, when combined with established techniques, offers new possibilities in tackling challenging neurovascular lesions. Future follow-up will be crucial to assess long-term outcomes and the potential need \nfor\nadditional\ntreatment.\nThis\ncase\ncontributes to the growing body of evidence supporting multi-modal, staged approaches in the management of complex CCFs, and underscores the ongoing evolution of \nneurointerventional\ntechniques\nin\naddressing these challenging vascular anomalies. \nDATA AVAILABILITY: \nFurther information regarding the data used for this work can be obtained from the \tcorresponding \tauthor \tupon reasonable request. \nFUNDING: \nThis work received no external funding. \nCONFLICT OF INTEREST: \nThe authors have no conflicts of interest to declare and is in agreement with the contents of the manuscript. \nREFERENCES: \n1.Texakalidis P, Tzoumas A, Xenos D, Rivet DJ, Reavey-Cantwell J. Carotid cavernous fistula (CCF) treatment \n22 \n\nJournal of Cardiovascular, Neurovascular & Stroke \nhttps://mycvns.com \nFistula Following Traumatic Fall: A Case Report. J Belg Soc \nRadiol. 2024 Sep 17": null, "108(1):83. doi: 10.5334/jbsr.3696. PMID: 39308750": null, " PMCID: \nPMC11414464 \n6.Lin, N., Ho, A., & Arthur, A. S. (2020). Direct carotid-cavernous fistula: Current endovascular \ntreatment strategies. \nInterventional Neuroradiology, 26(4), 391-400. \n7.Kim, D. J., Kim, D. I., Suh, S. H., & Kim, B. M. (2021). The use of PHIL as a liquid embolic agent in neurointervention. American \nJournal of Neuroradiology, 42(3), 527-534. \n23 \n\nJournal of Cardiovascular, Neurovascular & Stroke \nhttps://mycvns.com \nFIGURE LEGENDS: \n\nFigure 1: Cerebral angiogram pre procedural showed a right direct CCF (arrow). \n24 \n\nJournal of Cardiovascular, Neurovascular & Stroke \nhttps://mycvns.com \n\nFigure 2: Partial occlusion of the CCF after 1st embolization procedure with seven fibered coils (arrow) successfully deployed into the venous sac of the cavernous sinus. \n25 \n\nJournal of Cardiovascular, Neurovascular & Stroke \nhttps://mycvns.com \nA) \nB) \nC) \nFigure 3. Cerebral angiogram, right ICA. A: lateral projection pre. B: AP projection post. C: Lateral projection post. Second embolization successfully deployed one fibered coil (arrow) followed by the injection of 1 ml of Precipitating Hydrophobic Injectable Liquid (PHIL) 30%. Cerebral angiogram post procedure showed significant reduction of the CCF flow. \n26 \n\nJournal of Cardiovascular, Neurovascular & Stroke \nhttps://mycvns.com \n\nFigure 4: MRA 5 month later showed complete resolution of right CCF (arrow) with patient symptoms have improved. \n27": null}