P058 Treatment strategies for bilateral intracranial artery complications following transnasal giant pituitary adenoma surgery

<h3>Introduction</h3> Carotid-cavernous fistulas (CCFs) are rare yet pivotal complications following head trauma in 0.2% of cases. Type-D CCFs, resulting from disruptions in the cavernous portion of the internal carotid artery (ICA), present high-flow communications between arterial and venous systems. Elevated blood pressure in the cavernous sinus compresses nearby nerves (III, IV, V, and VI). The symptoms resemble those associated with traumatic skull base fractures, complicating diagnosis. Treatment modalities include medical management, manual compression therapy, surgical management, stereotactic radiosurgery, and endovascular repair via transarterial, transvenous or combined routes. <h3>Case Description</h3> (A 33-year-old man presented with persistent symptoms, including a pulsating hum sensation in the head, periorbital swelling, double vision, and transient liquorrhea, six months after sustaining fractures of the face and head bones. Examination revealed left periorbital edema, impaired photoreaction, chemosis, exophthalmos, convergent strabismus, and VI nerve paresis. CT angiography confirmed a left-sided CCF (Type-D). <h3>Results</h3> Coil embolization was performed using a transvenous approach through a 0.017’ Microcatheter. Single-lumen balloon 6x20 was positioned near the defect of the ICA with transarterial approach through 6f 0.088’ LongSheath and 0.017’ Microcatheter. Coils, including Balt Optima Complex, were used to close the fistula, with balloon inflation in the ICA to prevent coil migration. Control angiograms demonstrated successful closure of the fistula and decreased pressure in the ophthalmic veins. Postoperatively, the patient experienced regression of pulsating hum and periorbital swelling, along with improved VI nerve paresis and restored photoreaction, underscoring the effectiveness of combined (transarterial+transvenous) embolization for this rare complication.