Carotid-cavernous Fistula Caused by Vessel Injury while Withdrawing a Stent Retriever during Mechanical Thrombectomy for Acute Ischemic Stroke: A Case Report

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Objective: A rare complication, a carotid-cavernous fistula (CCF), that developed during stent retriever thrombectomy for acute ischemic stroke is reported.

Case Presentation: A 67-year-old woman with consciousness disturbance and left hemiparesis underwent stent retriever thrombectomy for acute right M1 proximal occlusion of the middle cerebral artery (MCA) 6 hours after onset. There were several tortuous vascular segments in the approach route. Strong resistance was felt while the stent retriever was withdrawn. The cavernous segment of the internal carotid artery (ICA) was stretched by anchoring of the balloon and the stent retriever. Angiography immediately after thrombectomy showed a CCF although successful recanalization was obtained. This was probably caused by pull-out vessel injury of the meningohypophyseal trunk branching from the cavernous segment of the ICA. The CCF was treated with transvenous coil embolization 3 weeks after thrombectomy and disappeared angiographically.

Conclusion: If there is strong resistance while pulling back a stent retriever, the risk of vascular injury, such as a CCF, should be kept in mind.