Introduction
: Traumatic carotid‐cavernous fistulas (tCCFs) represent abnormal vascular shunt between the carotid artery, in its cavernous segment, and the cavernous sinus, after direct or indirect trauma. Literature on tCCF associated with gunshot wounds (GSW) is scarce and is unique due to potential risk of exsanguination or bleeding into the brain proper. Furthermore, the management of tCCF in the GSW population is particularly relevant as gunshot patients represent a unique challenge be it due to the presence of concomitant cranio‐cervical vascular injury, other organ involvement, or contraindications for anticoagulation and /or antithrombotic use.
Methods
: Case presentation
Case A
Patient is a 23 y/o female with GSW to the right side of the head with multiple skull base fractures and right temporal lobe penetrating injury with retained bullet fragment, traumatic subarachnoid hemorrhage in the basal cisterns, diffuse cerebral edema, and a 5mm right to left midline shift. Patient also has a high‐flow right tCCF with significant arterialization of cortical veins. Patient underwent venous coiling of the cavernous sinus with flow diverter stents in the arterial wall of the cavernous segment of the carotid artery. The patient remained in the hospital fifty‐one days and suffered multiple neurological complications, including cerebral vasospasm, development of a pseudoaneurysm in the right anterior choroidal artery that was embolized, and hydrocephalus, requiring ventriculo‐peritoneal shunting (VPS). Patient had a GOSE 2 at the discharge to a long‐term acute care facility.
Results
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Case B
Patient is a 30 y/o male with GSW to the left side of the head with left hemispheric subdural hematoma, left temporal lobe injury, and diffuse traumatic subarachnoid hemorrhage. The injury also resulted in a temporal bone fracture, lateral to the carotid canal, and extensive left facial fractures. Patient also has a high‐flow left tCCF that was also treated successfully with cavernous sinus coiling with flow diverter stenting of the carotid artery at the site of the fistula after initiating antithrombotic agents. Post the tCCF repair the patient developed a CSF leak that necessitated an extensive surgical repair that would not have been possible while on antithrombotic agents. At this point, the patient underwent balloon test occlusion (BTO) and sacrifice of the carotid artery at the site of the fistula. Patient was discharged to acute rehab facility with a GOSE of 5.
Conclusions
: Traumatic CCF may occur in patient with gunshot wounds to the head, representing an extreme of penetrating mechanisms associated with this type of injury. Current penetrating brain injury guidelines are outdated and provide no consensus on management of this condition. Embolization of the fistula, flow diversion via stenting of the fistula site and finally vessel sacrifice are viable options depending on the size of the fistula, flow grade, collateral flow, phase on injury, and concomitant injury that may dictate permissibility of antithrombotic therapy.
Carotid-cavernous fistulas
