Endovascular Management of the Traumatic Cerebral Aneurysms Associated with Traumatic Carotid Cavernous Fistulas

BACKGROUND AND PURPOSE: Simultaneous traumatic carotid-cavernous fistulas (TCCFs) and traumatic cerebral aneurysms (TCAs) of the internal carotid artery (ICA) are rare. We describe the pitfalls of detecting a TCA before TCCF occlusion and the endovascular management of the TCA and TCCF. METHODS: Over 12 years, 156 patients with TCCFs were treated at our institute. In four men (mean age, 34 years), associated TCAs were detected before (n = 1) or after (n = 3) endovascular occlusion of the TCCFs. Causes for the missed detection of the TCA before TCCF occlusion were masking by a parent artery and fistula drains (n = 1), steal phenomenon (n = 1), and a latent period (n = 1). The TCAs were in the supraclinoid ICA (n = 3) or the paraophthalmic artery (n = 1). Three TCAs were treated with the endosaccular placement of electrodetachable coils. RESULTS: Two TCCFs and associated TCAs were successfully occluded with preservation of the ICA. The paraophthalmic TCA was treated with coil occlusion of the TCA and TCCF. Spontaneous fatal rupture of the TCA occurred in one patient after subtotal TCCF occlusion. No notable procedure-related complication was observed in the other three patients. CONCLUSION: TCAs may be difficult to detect before treatment of the TCCF because it may be overlooked, a latent period may occur, flow may be shunted, or they may be masked by a nearby parent artery or fistula drains. As soon as a TCA is found, endovascular management should be initiated promptly.