Endovascular Treatment of High-Flow Carotid Cavernous Fistulas by Stent-Assisted Coil Placement

20-year-old woman (patient #3, Table 1) injured in an equestrian accident with multiple skull base fractures and bilateral carotid cavernous fistulas. A, Lateral projection of right common carotid artery arteriogram shows type A carotid cavernous fistula with no filling of the intradural segment of the internal carotid artery. Note prominent intracranial and orbital venous drainage. B, Lateral projection of right vertebral artery arteriogram demonstrates forward filling into right internal carotid artery. No demonstration of the communication between the proximal and distal internal carotid artery is seen. C, Lateral projection of right internal carotid artery angiogram following stent deployment with reconstruction of the vessel shows that there is now brisk antegrade filling of the internal carotid artery distal to the site of the fistula. D, Lateral projection of left internal carotid artery arteriogram shows type A carotid cavernous fistula. Although there is antegrade flow distal to the site of the fistula, the course and caliber of this segment of the internal carotid artery could not be determined. E, Lateral projection of left internal carotid artery arteriogram after stent deployment shows improved visualization of the cavernous segment of the internal carotid artery. Venous drainage to orbital veins persists. F, Lateral unsubtracted projection demonstrates bilateral stents in place (arrows). G, Lateral right internal carotid artery angiogram, unsubtracted, shows an inflated balloon inside the stent (arrow). This was used during coil deposition. H, Lateral projection of left internal carotid artery arteriogram demonstrates persistent flow after extensive coiling. I, Lateral projection of left internal carotid artery arteriogram shows a small aliquot of liquid adhesive (arrow) that was instilled in the proximal portion of the superior ophthalmic vein. This resulted in complete closing of the fistula. J-K, Frontal and lateral projections of right internal carotid artery (J) and left internal carotid artery (K) on 3-month follow-up arteriogram demonstrate patency of both internal carotid arteries with antegrade filling of their branches, dense coil packing, and complete closure of the fistulas.