Ruptured Persistent Trigeminal Artery Causing Direct Cavernous Sinus Fistula Treated with Pipeline Embolization and Minimal Coiling

• Published in: World neurosurgery 2018-01, Vol.109, p.471-475.e1
• Main Authors: Yoon, Nam K., Awad, Al-Wala, Gee, James M., Taussky, Philipp
• Format: Article
• Language: English
• Subjects: Adult; Arteriovenous Fistula - etiology; Arteriovenous Fistula - therapy; Carotid Artery Injuries - etiology; Carotid Artery Injuries - therapy; Carotid Artery, Internal; Case report; Cavernous Sinus - injuries; Cavernous sinus fistula; Cerebral Arteries - abnormalities; Cerebral Arteries - injuries; Embolization, Therapeutic - instrumentation; Embolization, Therapeutic - methods; Equipment Design; Female; Humans; Persistent trigeminal artery; Pipeline; Rupture; Stent; Wounds, Nonpenetrating - complications
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2017.10.017

Rupture of a persistent trigeminal artery associated with development of a cavernous sinus fistula in a traumatic setting is rare. These arteries are typically treated with coil embolization of the cavernous sinus. We present the case of a 42-year-old woman who developed a direct cavernous carotid fistula after a motor vehicle accident. Angiographic imaging revealed a rupture point of a persistent trigeminal artery as it connected with the cavernous segment of the internal carotid artery, causing a cavernous sinus fistula. Coiling of the cavernous sinus was abandoned after placement of 1 coil because of coil herniation into the internal carotid artery. A Pipeline embolization device was placed to oppose the coil against the intima and keep the lumen open. The combination of coil embolization and flow diversion acutely decreased the fistulous flow. Surprisingly, an angiographic follow-up at 6 months showed complete fistula occlusion despite placement of only 1 coil into the cavernous sinus. We report a rare case where undercoiling of the cavernous sinus occluded a cavernous sinus fistula because of the adjunct use of a Pipeline embolization device in the presence of a traumatic rupture of a persistent trigeminal artery.