Endovascular targeted coil embolization using dual vessel approach for traumatic direct carotid- cavernous fistula following severe head trauma: technical notes

Direct carotid cavernous fistulas (dCCFs) represent different entitles from spontaneous cavernous sinus (CS) dural arteriovenous fistulas (CSAVFs). Traumatic dCCFs are direct arteriovenous communications between the internal carotid artery (ICA) and cavernous sinus, resulting from a traumatic tear of the horizontal or posterior ascending intracavernous segment of the ICA by skull fracture fragments. They are account for 0.2–0.3% of craniofacial trauma and a serious problem that results in neuro-ophthalmologic symptoms. Intracerebral hemorrhage followed by cortical venous reflux is a most serious complication. Although embolization of dCCFs with detachable balloons was previously accepted worldwide as the firstline therapeutic option because it is technically simple, these devices are currently unavailable and other treatment options have included coil embolization of the fistula to preserve the internal carotid artery. Therefore, sinus packing by coil embolization is now a first-line therapy, but there is the disadvantage of neuro-ophthalmologic symptoms by nerve palsy occurred in CS. In this study, we treated two patients with dCCFs caused by severe head trauma who underwent dual vessel approach to endovascular targeted coil embolization and successful resolution. We concluded that dual vessel approach to endovascular targeted coil embolization is an effective and safety technique among patients with traumatic dCCFs.