Deflation of Detachable Balloons in the Cavernous Sinus by
Percutaneous Puncture
1
John M . Jacobs, Geoffrey D. Parker, 1 and Ronald I. Apfelbaum 2
showed that the fistula was occluded (Fig. 1C). Immediately
after detachment, a sma ll leak developed , due to slig ht
shifting of the balloons (Fig. 1D) . After 48 hours, th ere wa s
no evidence of spontaneous thrombosis.
An additional balloon could not be passed through the
fistula on the second attempt due to the in situ balloons
obstructing t he fistula. The inferior petrosal sinus was
occluded on the ipsilateral side ; therefore , the on ly other
potential endovascular therapeutic options included occlusion of the internal ca rotid artery or retrograde transvenous
approach through the superior ophthalmic vein , whi c h can
be technically difficult.
To improve access through the fistula into the cavernou s
sinus , two of the balloons were punctured percutan eously
via the foramen ovale using a 21-G spinal need le without
complication (Fig. 1E). Three add itional Debrun balloon s
were then introduced into the cavernous sinus (total of four
inflated balloons) with com plete closure of the fistula.
Approximately 24 ho urs later , a sma ll leak was aga in
evident on exam ination.
Thi s leak also fa iled to throm bose spontaneously , and
further percutaneous puncture of three of the bal loon s wa s
performed before allowing an add itional balloon to be
introduced. On this occasion an 18-G needle was inserted
into the foramen ova le. Th is needle was used as an introducer for a second , slightly bent , 2 1-G Chiba need le, which
could be guided into the cavernous sinus to puncture th e
three balloons. The inferior aspect of the cav ernou s sinus
was now thrombosed , and the last balloon was wedged at
the fistula orifice. The fina l balloon resu lted in complete
closure of the fistula with preservation of th e interna l
carotid artery (Fig. 1F). Both the immed iate postdetachment and a follow-up angiogram 4 days later confirmed
satisfactory resu lts. In both instances the latex Debrun
balloons were punctured without difficulty . It is poss ible
that the more elastic sil icone balloons wou ld be harder to
puncture by this technique.
Summary: The authors show that percutaneous puncture of
balloons within the cavernous sinus is technically feasible and
allows further access to the cavernous sinus after balloon
detachment. Complete closure of a large carotid cavernous
fistula was achieved in the 37-year-old trauma victim they
treated using this technique.
Index terms: Fistula, carotid-cavernous; Fistula, therapeutic
blockade; Catheters and catheterization , balloons
Closure of traumatic carotid cavernous fistulae
using detachable balloons is well described (1-6)
in the literature. Occasionally, despite initial closure of the fistula, it may reopen after balloon
detachment due to slight movement or shifting
of the balloon. Gaining further access to the
cavernous sinus through the fistula can be problematic due to partial occlusion by the detached
balloon(s).
We describe a case where a high-flow traumatic carotid cavernous fistula recurred on two
separate occasions after balloon detachment.
Subsequent puncture of inflated , detached balloons in the cavernous sinus by a percutaneous
approach through foramen ovale allowed further
access to the cavernous sinus through the fistula.
Case Report
A 3 7-year-old man sustained severe head injury during
a motor vehicle accident. Five weeks later he developed
symptoms of a carotid cavernous fistula . His intraoc ular
pressure was raised (28 cmH 20).
Selective left internal carotid arteriography demonstrated a direct carotid cavernous fi stula of the C5 segment
of the cavernous carotid artery (Figs. 1A and 1B).
During an initial transarterial endovascular app roach ,
three #9 Debrun detachable latex balloons (lngenor, Paris ,
France) were placed through the traumatic ca rotid cavern ous fistula (TCCF) into the cavernous sinus. The angiogram
obtained just prior to detachment of the third balloon
Discussion
Traumatic carotid cavernous fistulae are due
to laceration of the internal carotid artery in the
cavernous sinus or rupture of C4 or C5 intracav-
Received September 24, 1991 ; accepted and rev ision requested February 9, 1992; revision received March 9.
1
Department of Radiology , Neuroradiology Section , Universit y of Utah , School of Medici ne, 50 North Medical Drive, Sa lt Lake City , UT 84 132.
Add ress reprints to John M. Jacobs, MD.
2
Department of Neurosu rgery , University of Utah , School of Medicine, Salt Lake City, UT 841 32.
AJNR 14: 175-177 , Jan / Feb 1993 0195-6108/ 93/ 1401-0175 © A m erican Soc iet y of Neuroradiology
175
176
A
D
JACOBS
AJNR: 14, January / February 1993
B
E
F
Fig. 1. A , Early arterial phase of internal carotid arteriogram (lateral projection) showing fistula site (arrow).
B, Later phase showing aneurysmal dilation of the cavernous sinus ( CS) and retrograde filling of the dilated superior ophthalmic vein
and numerous cortica l veins.
C, Appearance just prior to detachment of the third Debrun #9 latex balloon (B) showing occlusion of the fistula with preservation
of the internal carotid artery.
D, Angiogram obtained 48 hours later showing leakage around the balloons, which have migrated.
E, Fluoroscopic image showing needle placed percutaneously into cavernous sinus through foramen ovale (open arrow).
F, Final interna l carotid arteriogram showing occlusion of the fistula and preservation of the carotid artery. Metal clips mark deflated
balloons (arrows). There are two remaining inflated balloons (B).
ernous dural branches. Balloon occlusion is the
established method of choice for treatment of
these lesions when caused by carotid laceration
( 1-6). Although the literature indicates that the
lesion may thrombose spontaneously when only
minimal filling of the fistula persists after embolization (1) , this did not occur in our case.
The technique of percutaneous puncture of
Meckel's cave via foramen ovale is well described
in the neurosurgical literature (7) for the treatment
of trigeminal neuralgia by glycerol injection and
for biopsy of cavernous masses. This technique
requires fluoroscopic guidance with the patient
positioned in a submentovertex projection with
AJNR: 14, January / February 1993
15-20 degrees of contralateral rotation. The
needle is inserted 2 em lateral to the corner of
the mouth and advanced submucosally in the
sidewall of the oral cavity , medial to the ascending ramus of the mandible. Once Meckel's cave
is entered, the needle need only be advanced a
few millimeters with lateral fluoroscopic guidance
to reach the cavernous sinus. Although it is possible that cranial nerves might be injured by this
technique, in large series in which this technique
was used for glycerol injection of the trigeminal
nerve, other cranial nerve injury is exceedingly
rare and usually temporary. Since ophthalmoplegia is commonly associated with traumatic carotid cavernous fistula, detection of additional
injury to cranial nerves may be difficult. No complications occurred in this patient following percutaneous puncture of balloons on two separate
occasions by this method. The deflated balloons
remained in the cavernous sinus and contributed
to the volume of thrombogenic material present.
Interestingly, upon removal of the needle stillet in
the cavernous sinus, brisk arterial bleeding as one
might expect from a cavernous sinus in fistulous
communication with the internal carotid artery
was not noted. Rather, the bleeding was of a slow
venous nature. This is probably because the cavernous sinus is actually a septated structure.
Potentially , puncture of a cavernous sinus in
direct communication with the internal carotid
artery could result in life-threatening arterial
bleeding . For this reason , we had an uninflated
detachable balloon immediately available to occlude the internal carotid artery at the fistula if it
became necessary.
There are philosophical differences among
practitioners as to whether contrast medium or a
polymer such as HEMA (hydroxyethylmethacrylate) is the best agent to be placed inside a
detachable balloon. Had HEMA or a similar polymer been used in this instance, the deflation
technique described would not have been suitable, since these polymers are semisolid . In any
DEFLATION OF DETACHABLE BALLOON S
177
event , it is unlikely that the agent used to fi ll t he
balloons had an y impact on t he recurrence of t he
fistula . In serial skull films , the balloons did not
show evidence of deflation , but rather had migrated or shifted wi thin a very patulous cavernous
sinus . We attribute this effect to t he presence of
soft thrombus within the cavernou s sinus, whic h
yielded to the pulsatile mass effect of the balloons
in contact with the carotid artery .
Percutaneous puncture through foramen ovate
for trigeminal neurolysis is an established and
safe neurosurgical technique. Others have reported this approach for deflation of detac hed
silicone balloon(s) in the cavernou s sinus when
there is chronic pain associated with treatment
of TCCFs (8) , or for biopsy of masses in t he
cavernous region . Percutaneous puncture of nonideally placed balloons within the cavernous sinus
was technically feasible in this case and allowed
further access to the cavernous sinus after balloon detachment, ultimately allowing complete
closure of this large TCCF with presentation of
the parent artery .
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