Cavernous Sinus Thrombosis

Cavernous sinus thrombosis (CST) is a rare diagnosis although must be included in the differential of headache. CST is either infectious or aseptic. Aseptic thrombosis usually occurs secondary to trauma or is post surgical. Sinusitis appears to be the most common cause for septic CST. Otitis media, facial cellulitis (located medial third paranasal) and odontogenic infections are also commonly implicated. Cavernous sinus thrombosis (CST) is a rare phenomenon that requires clinical suspicion and emergent imaging for correct diagnosis. Mycotic aneurysm is a rare complication of cavernous sinus thrombosis and may be treated with antibiotics, carotid ligation, internal carotid artery balloon occlusion, or Guglielmi detachable coil (GDC) embolization.

Fate of Clots in Patients With Subarachnoid Hemorrhage After Different Surgical Treatment Modality: A Comparison Between Surgical Clipping and Guglielmi Detachable Coil Embolization

BACKGROUND: Subarachnoid clot is important in the development of delayed vasospasm after subarachnoid hemorrhage (SAH). OBJECTIVE: To compare the clearance of subarachnoid clot and the incidence of symptomatic vasospasm in surgical clipping and embolization with Guglielmi detachable coils for aneurysmal SAH. METHODS: The subjects were 115 patients with Fisher group 3 aneurysmal SAH on computed tomography scan at admission whose aneurysm was treated by surgical clipping (clip group; n = 86) or Guglielmi detachable coil embolization (coil group; n = 29) within 72 hours of ictus. Software-based volumetric quantification of the subarachnoid clot was performed, and the amount of hemoglobin in drained cerebrospinal fluid was measured. RESULTS: Clearance of the subarachnoid clot on the computed tomography scan was rapid in the clip group until the day after the operation but slow in the coil group (58.9% removed vs 27.8% removed; P = .008). However, postoperative clearance of the clot occurred more rapidly in the coil group. Reduction of the clot until days 3 through 5 did not differ significantly between the 2 groups (72.9% removed vs 75.2% removed). The amount of hemoglobin in the clip group was > 0.8 g/d until day 3 and then gradually decreased (n = 15), but hemoglobin in the coil group remained at > 0.8 g/d until day 5 (n = 17). The incidence of symptomatic vasospasm did not differ between the groups. CONCLUSION: Subarachnoid clot can be removed directly during surgical clipping, which is not possible with endovascular treatment. However, the percentage reduction of the clot on days 3 through 5 did not differ between the 2 groups.

Microcatheter Neck Bridging and Incorporated Branch Vessel Protection for Coil Embolization of a Wide-Neck Ruptured Aneurysm: Technical Case Report

BACKGROUND AND IMPORTANCE: A novel technique in which microcatheter neck bridging of a ruptured wide-neck posterior communicating artery aneurysm was performed by intra-aneurysmal catheter navigation into a fetal configuration posterior cerebral artery (PCA) branch vessel arising from the sac. CLINICAL PRESENTATION: An 88-year-old woman with a Hunt and Hess grade 1 and Fisher grade 4 subarachnoid hemorrhage was identified as having a wide-neck posterior communicating artery aneurysm and an isolated fetal configuration PCA with origins from the aneurysm sac. Delivery of a bare platinum Guglielmi detachable coil within the aneurysm lumen resulted in persistent coil prolapse into the parent vessel with occlusion of the incorporated vital PCA origin. A microcatheter was then navigated through the aneurysm lumen and into the fetal configuration PCA. This was retained within the PCA with resultant aneurysm neck narrowing and branch vessel protection. A second microcatheter was placed in the aneurysm lumen for coil delivery. Complete aneurysm occlusion with patency of the PCA without coil loop prolapse into the parent vessel was achieved. CONCLUSION: The presence of normal branch vessels arising from the dome is a limitation for endovascular techniques. To the best of our knowledge, no prior description of a dual-microcatheter technique with selective catheter placement within an important intra-aneurysmal branch vessel has been published. The vital branch vessel was protected and the wide-neck aneurysm completely occluded. Novel placement of microcatheters further expands the range of complex configuration aneurysms amenable to endovascular coiling.

Successful Transarterial Guglielmi Detachable Coil Embolization of Post-Traumatic Fistula between a Posterior Communicating Artery Aneurysm and the Cavernous Sinus

We describe a case of a post-traumatic posterior communicating artery (PCoA) aneurysmcavernous sinus fistula, which is an extremely rare complication of craniocerebral trauma, successfully treated with endosaccular coil embolization via transarterial route. Endosaccular embolization with Guglielmi detachable coils via transarterial route appears to be a feasible, effective and minimally invasive option for the treatment of post-traumatic fistula between the PCoA aneurysm with a small ostia and the cavernous sinus in the subacute phase.