| Research backroundTraumatic carotid cavernous sinus fistula (TCCF) refers to be an abnormal arteriovenous communications between cavernous sinus segment of the internal carotid or its branches and cavernous sinus venous system, which is caused by trauma. The classic presentation of TCCF is ophthalmoptosis, conjunctival congestion, chemosis, cephalic bruit and diminution of vision. Cavernous sinus is a trabeculated venous cavity invested by the dura mater and contains several neural and vascular structures where internal carotid artery (ICA) comes through. TCCF are reported to occur in2.5%of craniocerebral trauma patients and in up to75%of all the carotid cavernous sinus fistula patients. When involving the fracture of the skull base, the morbidity of the disease can be up to4%. Among them the occurring rate of young men is relatively higher.ONP is one of the serious clinical manifestations associated with traumatic carotid-cavernous fistula (TCCF). Once forming carotid cavernous sinus fistula after trauma, direct or indirect damage mechanism may result in partial or even complete dysfunction of oculomotor nerve after a period. With the pressure of draining veins increasing gradually, the presentation of conjunctival congestion, chemosis, ophthalmoptosis and cephalic bruit becomes more and more outstanding. Additionally, the majority of patients complain of visual disturbance, including diplopia, blurry vision and orbital pain. Oculomotor nerve, optic nerve, trochlear nerve and abducent nerve can be injuried if TCCF is not treated in time once it happened. To make things worse, serious complications can be occurred, such as permanent vision loss, eye movement dysfunction, hemiplegia, aphasia and even intracranial hemorrhageAt present, with the continuous renewal of endovascular embolization material improvement, embolization technology becoming mature, treatment becoming more and more experienced, as well as deeper research made by many scholars, the diversity of the treatment option for TCCF and prognosis of carotid cavernous sinus fistula may be also getting better and better. Currently, the mainly used embolism materials are balloons, micro coils, Onyx, NBCA, cover stents, etc. Endovascular embolization with detachable balloons has the advantages of less invasive, simple and the accurate curative effect, economy and lower recurrence rate which is the preferred method to treat TCCF and is alternative method to surgical intervention.The main purpose of treatment TCCF is to protect the eyesight, eliminate intracranial murmur, promote the restoration of nerve function and reduce the risk of intracranial hemorrhage, etc. The first-rate treatment method is not only to block fistula but also to keep the liquidity of the internal carotid artery. Compared with the surgery, endovascular embolization of TCCF with detachable balloons is a less intrusive and relatively economical way which is a preferred method should be considered first. For some patients whose fistulas of cavernous sinus are complicated need to be selectively blocked of the pain side of internal carotid artery fistula. In addition, sometimes, multiple materials also need to be combined use to embolize the fistula to achieve the goal of occlusion fistula.By collecting a large number of TCCF cases, we studied the patient’s medical history, clinical manifestation, imaging examination, treatment, material used, prognosis and follow-up datas by filtering and inclusion criteria, to find out the related factors which affected the postoperative recovery time of oculomotor nerve paralysis. At the same time, we found out the risk factors which affected the recovery of the oculomotor nerve after operation by using statistical methods so that we could provide some references for clinical treatmentPurpose:Recovery of traumatic carotid-cavernous fistula-induced oculomotor nerve paresis (ONP) after endovascular embolization with detachable balloons has not yet been adequately evaluated. This study was performed to make a deeply analysis of the factors which affect the prognosis of ONP after endovascular treatment of traumatic carotid-cavernous fistula (TCCF).Our purpose was to summarize the clinical experience of carotid cavernous sinus fistula treated by detachable balloons and provided some the oretical basis to prevent and reduce complications for the future, as well as provided some references for clinical to endovascular treat TCCF by detachable balloons.Materials and methods:We retrospectively evaluated the clinical characteristics and the outcome of oculomotor nerve function in a series of98consecutive patients with ONP due to traumatic carotid-cavernous fistula which were endovascular treated with detachable balloons. The factors of gender, age, the location of the fistula, the preoperative degree of oculomotor nerve paralysis, side of ophthalmoptosis, the number of detachable balloons used, the state of the internal carotid artery, and the length of preoperative oculomotor nerve paralysis symptoms to the time of treatment are all collected.Firstly, all patients were put into8F femoral sheath by the conventional method of using Seldinger puncture the right femoral artery. Secondly, cerebral angiography imaging was performed to confirm tube size and location of the fistula of the cavernous sinus by using5F catheter and then put8F guide catheter on the petrous part (C5segment) of affected side internal carotid artery. The whole body was immediately heparinized according to the weight of patient. All the operations were conducted under fluoroscopy (AXIOM artis DTA machine). Choose the proper type of bolloon and inotoll it at the tin of Mogin RDRF mione sotheter then flooting glean with blood stream to fistula and into the cavernous sinus. Nonionic isotonic iodine contrast agent should be slowly filling the balloon and timely projection until the fistula was blocked.Postprocedure heparin therapy was routinely reversed with the administration of protamine (10mg/1000U sodium heparin). Patients were stayed in bed for24h to72h after embolization and they were also given expansion and anticoagulant drugs if it was necessary. All statistical data analysis was used SPSS13.0statistical analysis system. Enumeration data was described by constituent ratio or ratio, and measurement data was described by mean±tandard deviation. One sample t test was used to compare the means of two independent sample groups and paired datum if the datum was normal distribution. If the datum didn’t obey the normal distribution, nonparametric test should be used. Inspection level was a=0.05and only a value<0.05was considered to be statistical significant. Analyze the related factors which influenced the prognosis time of oculomotor nerve palsy after endovascular embolization and summarize the clinical experience of the application with detachable balloon, as well as the attention needed to be payed for the treatment of TCCF.Results:Ninety-eight consecutive patients (62men,36female, mean age34.2+12.7years) presenting with ONP underwent endovascular treatment with detachable balloons were enrolled in this study. ONP was complete in22(22.4%) patients and partial in76(77.6%) patients. The location of ten fistula were located on C2segment (10.2%), twenty-nine were located on C3segment (39.6%), fifty-four opened at C4segment (55.1%) and five was seated at C5segment (5.1%). The manifestation of ophthalmoptosis was on the left in50(51%) patients,41(41.8%) on the right and7(7.1%) on both sides. The mean interval between the onset of ONP and endovascular treatment was334.9days (range9-3655days) and the mean time of ONP recovery was33days (range3-180days). Ninety (91.8%) patients were successfully occluded by single-session endovascular embolization. Retreatments by trans-arterial routes had to be performed in8(8.2%) patients because of recurrent fistula occurring within weeks after embolization. ONP was recovered completely in all the patients, among vhom4(4.1%) were treated with occlusion of internal carotid artery. Factors showing significant association with the recovery time of ONP were the location of he fistula (p=0.007), the degree of preoperative ONP (p=0.003), the number of letachable balloon used (p=0.000) and the length of ONP before endovascular reatment (p=0.000).Overall, oculomotor nerve function of all the patients underwent endovascular mbolization with detachable balloons experienced complete recovery. The levator alpebrae and medial rectus muscles demonstrated rapid recovery and the)arasympathetic fibers of the pupil and the superior and inferior rectus muscles also got a good recovery.No correlation could be found between age and the length of ONP recovery p=0.355), and no statistically significant correlation could be found between gender and the ONP recovery time. Also side of ophthalmoptosis (p=0.067) and status of CA (p=0.869) did not significantly contribute to the length of ONP recovery.According to the location of fistula, ten were located on C2segment (10.2%), wenty-nine were located on C3segment (39.6%), fifty-four opened at C4segment55.1%) and five was seated at C5segment (5.1%). We found that there is a significant correlation between the location of fistula and the length of ONP recovery p=0.007). When further study was made, markedly statistical significance could be found between C4segment (Cavernous sinus segment, n=54,55.1%) and non-cavernous sinus segment (n=44,44.9%)(Z=-3.044; P=0.002)According to the degree of preoperative ONP, patients were divided into two groups:Partial and completely paralysis of the oculomotor nerve (n=76,77.6%and n=22,22.4%respectively). A significant correlation could be found between the legree of preoperative ONP and the length of ONP complete recovery (p=0.003).According to the number of detachable balloons used,84(85.7%) patients were reated with less than3balloons, and14(14.3%) were treated with3or more alloons. Follow-up results showed that the number of detachable balloons used was significantly associated with the length of ONP complete recovery (p=0.000).According to the status of internal carotid artery, ninety-four patients (95.9%) had completely occluded the fistulas and reserved the parent artery, while the rest of four patients (4.1%) had to occlude the parent artery because of serious steal flow of blood and other reasons. In our series, the status of internal carotid artery had no significant effect on the ONP recovery time (p=0.869).In our study, the length of ONP before endovascular treatment (334.9, mean days) had a significant correlation with the length of ONP complete recovery (33, mean days)(r=0.584, p=0.000). The longer of ONP lasted preoperative, the more time of ONP need to be recovered.Conclusion:Endovascular treatment of traumatic carotid-cavernous fistula-induced ONP with detachable balloons is a safe and effective method. The Length of ONP before endovascular treatment, the location of the fistula, the degree of preoperative ONP, the number of detachable balloons used were the statistically significant predictors of the length of ONP complete recovery. Endovascular embolization with detachable balloons to treat TCCF should be preferentially considered. Once traumatic carotid-cavernous fistula formed, patients should be treated timely and effectively. |
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