特発性CCFに対し, 外頸動脈の塞栓・結紮術と照射が有効であつたので報告した. 症例は62才女性で, 両側内・外頸動脈より供血を受けるmixed typeのCCFであった. Matas testで若干の効果がみられたため, 外頸動脈の塞栓・結紮術を施行した. 塞栓・結紮術は局所の血流停滞を惹起し血栓形成に有用であつた. また, 照射は血管内膜の肥厚・増殖をもたらし, 血栓形成に有効であつた.
本症例のようなCCFの場合, 外頸動脈の塞栓・結紮術と照射は一度は試みてみるべき価値ある治療法と考えられた.

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Traumatic carotid-cavernous fistula is a disease in which an arteriovenous fistula forms between the cavernous sinus of the brain and the internal carotid artery passing through it. It is often associated with severe cases of head trauma, especially with skull base and mesofacial fractures. Here we report a case of mandibular fracture alone with an internal carotid cavernous sinus fistula.

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Long-term follow-up results were analysed in 29 cases of spontaneous carotid-cavernous fistulas. All were low flow type of spontaneous carotid-cavernous fistulas, and were treated with conservative therapy.
A complete regression of symptoms was noted in 25 cases, and a moderate regression in 4 cases. The regression of symptoms was usually delayed in patients less than 59 years old, and in cases with multiple draining veins.
Conjunctival injection was usually recognized within one month after the onset and disappeared more than one year later. Diplopia and blepharoptosis were usually recognized within one month after the onset and disappeared in 6-12 months. Exophthalmos and tinnitus were usually recognized within one year after the onset and disappeared within one year. Visual disturbance was usually recognized more than one year after the onset and disappeared within one year after the appearance.
From these results, it is seen that spontaneous carotid-cavernous fistulas show a very high incidence of spontaneous regression of symptoms, and conservative treatment is initially recommended.

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After super-selective embolization of the external carotid arterial branch, some improvement in the symptoms of two patients (63-year-old female, 68-year-old female) were observed, but some symptoms continued after the embolization. One month after the embolization, external irradiation (10 MeV X ray, 2Gy/day, 5fr/W, total 30Gy) was administered to the region of the fistula. An angiogram after completion of the irradiation showed complete disappearance of CCF, and almost complete improvement of symptoms was observed. For three years following the completion of irradiation, neither recurrence of sympoms nor side effects were noted.

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In this paper, eight cases of spontaneous carotid-cavernous fistula (CCF) are presented and their treatment is discussed.
Three were treated with electrothrombosis by copper needle insertion, three were treated with irradiation and two were observed conservatively.
Angiographic examination showed that the CCF disappeared completely in all three patients who underwent electrothrombosis, but in two cases clinical complications appeared; i. e., transient oculomotor palsy and Gerstmann's syndrome due to stenosis of the internal carotid artery.
Lineac irradiation was applied to the fistula (100 rad per day, three times per week, total dose 4000 rad).
Clinical symptoms of all three patients improved, and angiographic examination showed that the fistulas were reduced in size in two cases and disappeared in the other.
Angiographically, spontaneous CCF were divided into three groups: localized, scattered and mixed type.
The scattered type was easily curable with any treatment, which is assumed to be because of the low blood flow at the fistula in this type.
Irradiation of spontaneous CCF is thought to be feasible as a first-choice treatment because it is non-invasive and effective.

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【目的】血栓化巨大内頚動脈瘤のendovascular trapping を行う際に，遠位側の内頚動脈を安全に閉塞するため工夫した症例を報告する．【症例】75 歳女性．Mass effect で発症した左部血栓化巨大内頚動脈瘤に対して虚血耐性を確認した後，局所麻酔下にendovascular trapping を施行した．動脈瘤遠位側の左内頚動脈内には，あらかじめ椎骨動脈より左後交通動脈を経由してカテーテルを挿入し，動脈瘤内にコイルが入らないように遠位側を閉塞した．【結論】血栓化巨大内頚動脈瘤のendovascular trapping に際して後交通動脈が利用できる可能性がある．

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症例は73歳男性である．発熱と後頭部痛，眼球運動障害，複視，右眼瞼下垂のために入院となった．入院後に頭痛と眼症状の増悪がみられ，意識障害を呈した．頭部MRIでは斜台部造影増強効果と鞍上部・部に造影増強効果をもつ腫瘤性病変をみとめ，頸部CTでは左内頸静脈の血栓性閉塞をみとめた．血液培養結果からFusobacterium nucleatumによるLemierre症候群と診断し，抗菌薬と経口ステロイド薬の併用による治療をおこなったところ症状は消失した．Lemierre症候群に起因する斜台骨髄炎，病変はきわめてまれであるが，ステロイド併用によりすべての症状を治療しえた貴重な症例であった．

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Traumatic carotid-cavernous sinus fistula (t-CCF) is an arteriovenous fistula formed by the tearing of the internal carotid artery running in the cavernous sinus, accompanied by head/maxillofacial injuries. Patients with this disease rarely show spontaneous closure and often require urgent endovascular treatment. We report a case of t-CCF that developed following jaw and zygoma fractures and was successfully treated by manual carotid compression. A 35-year-old man was referred to our hospital to undergo treatment for multiple maxillofacial fractures. On the first day after injury, open reduction and internal fixation of the mandible were conducted with the patient under general anesthesia. On the fifth day after injury, diplopia of the left eye suddenly appeared. On the seventh day after injury, left exophthalmos/edema of the left upper eyelid/left abducens nerve palsy/bilateral ptosis, and hyperemia of the bulbar conjunctiva appeared. On the 15th day after injury, cerebral angiography revealed a definitive diagnosis of t-CCF. Supervised manual carotid compression during the waiting period before endovascular treatment led to improvement in various symptoms from the 19th day after injury. Cerebral angiography, which was performed again for endovascular treatment, revealed that arteriovenous fistula resolved spontaneously. Therefore, treatment was discontinued, and the patient was followed up with a conservative approach. By 9 months after injury, all symptoms, including left oculomotor nerve palsy had disappeared. There was no evidence of recurrence 10 years after injury.

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　重症頭部外傷による脳血管損傷に続発し，内頚動脈瘤や解離，内頚動脈

瘦（carotid‒cavernous fistula: CCF）などが発生することはよく知られている．これらに対する脳血管内治療の有効性は高く，確実な治療が可能であるため早期の診断が重要である．我々は多発外傷における外傷性CCFの合併および自然治癒例で，体幹部外傷の治療を優先する必要があり，外傷性くも膜下出血の存在を認知しつつも診断の遅れと重篤な後遺症をきたすことになった症例を経験したので報告する．症例は17才男性．交通事故による多発外傷であり，頭部CTにて外傷性くも膜下出血および頭蓋底部分に気脳症を認めていたものの，脾損傷による腹腔内出血・出血性ショックのため，その診断および治療が優先された．２日目の頭部CTでは脳梗塞が認められた．当初より大量の鼻出血，頭蓋底骨折と，症候学的には外傷性内頚動脈損傷を示唆していたが，眼症状なく重度の意識障害のため病態が十分把握できず，５日目にCTAを施行したところCCFおよび内頚動脈解離が確認された．すでに広範な脳梗塞が出現しており，患者の状態から保存的加療を選択した．follow‒up CTによりCCFの自然治癒が確認されたが，患者はmRS 5と重度の機能障害が残存し入院60日で転院となった．重症頭部外傷では，脳血管損傷の可能性を考え，それを示唆する症状，画像所見を認めた場合には血管造影など早期の診断により治療につなげることが重要である．

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　Traumatic carotid-cavernous sinus fistula (CCF) is a rare disorder in which the internal carotid artery is injured by trauma, forming an arteriovenous fistula in the cavernous sinus. We report a case of traumatic CCF associated with jaw fractures. A 37-year-old male patient was referred to our emergency room in November 2022 due to injuries sustained in a traffic accident. He was conscious with JCS 10, and left-sided eye protrusion and mandibular dislocation were observed. CT revealed a left-sided maxillary fracture, mandibular fractures, and dilatation of the left-sided superior ophthalmic vein. A cerebral angiography was performed on the 6th day of admission, and a definitive diagnosis of traumatic CCF was made. On the 8th day of admission, the patient underwent open reduction and fixation of the mandibular fracture, and on the 12th day of admission, a coil embolization and parent artery occlusion (internal trapping) were performed in the neurosurgery department. No postoperative recurrence has been observed at 18 months after the surgery. Even in cases comprising jaw fracture only, strict follow-up is necessary while keeping in mind the possibility of traumatic CCF developing.

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Objective: We report a case of carotid-cavernous sinus fistula (CCF) occurring as a complication of surgery for palate cancer.

Findings: A 64-year-old man presented to us with palate cancer. We performed bilateral neck dissection, resection of the palate cancer, and reconstruction using a left forearm flap. On the day after the surgery, the patient developed chemosis, ptosis, dilatation of the pupil, and ocular motility disorder in his right eye. On the basis of the findings of head MRI, MRA and cerebral angiography, we made the diagnosis of CCF. We occluded the fistula by endovascular embolization with coils. While the chemosis began to improve gradually, the other symptoms remained. At 14 months after the first operation, strabismus surgery was performed. Ever since the surgery until date, the patient has shown no evidence of recurrence of either the palate cancer or the CCF.

Conclusion: CCF is commonly caused by direct head injury, but has rarely been reported after craniofacial surgery. We considered cutting of the pterygoid process as the reason for the occurrence of the CCF in this case. Appropriate and early treatment of CCF is useful for preventing the complications of cerebral infarction and bleeding.

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SCCFの治療には沢山の報告があるが, いまだ議論のあるところである. 3例について報告する. 第1例は57歳女性, 右脳血管写で低還流CCF(BarrowのType B)をみた. Matas手技のみで消失した. 第2例は62歳女性, 両側血管写で低還流CCFをみ(Type D), Matas手技, 左外頸動脈の塞栓, 結紮にて軽快した. 第3例は66歳女性, 両側血管写にて高還流CCF(Type D)をみた. Matas手技と経静脈的塞栓術を行った. 塞栓は白金コイルを内頸静脈, 下錐体静脈を経てに充填した. まとあると, SCCFの治療は, 最初Matas手技を2から4週間行い, 効果がみられない場合, 経静脈的塞栓術を施行する. カテーテルと塞栓物質の技術的進歩によって, 経静脈的塞栓術はSCCFにとって最も効果的, 安全な方法の1つと考えられる.

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Traumatic carotid-cavernous sinus fistula (traumatic CCF) is a rare disorder in which the internal carotid artery is torn and forms an abnormal interconnection with the cavernous sinus as a result of craniofacial injuries. We describe a case of traumatic CCF occurring during follow-up after open reduction and internal fixation of a mandibular fracture. The patient was a 56-year-old woman who was injured in a motorcycle accident. She had a mandibular fracture without skull base or midface fracture. Conjunctival hyperemia of the left eye, exophthalmos, and vascular bruits in the palpebral region developed 87 days after injury. Brain computed tomography revealed left exophthalmos and abnormalities in the cavernous sinus region, as well as superior ophthalmic vein distention. Left carotid angiography revealed shunt flow into the cavernous sinus, leading to a diagnosis of CCF. Left internal artery occlusion was performed using a Guglielmi detachable coil. The present case suggests that delayed cerebrovascular disorder can occur during postoperative follow-up, even in patients with mandibular fracture alone.

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Nine cases of cavernous portion aneurysm (AN) were treated by direct surgery.
One AN was a persistent trigeminal artery AN at the C_4-5 portion, five ANs were located at the C₃ portion and the other three were ophthalmic ANs of the subchiasmal type at the C₂ portion.
In four cases, subarachnoid hemorrhage occurred as a result of a saccular aneurysm located at the C₂ portion (three cases) and at Acom accompanied by a C₃ portion AN (one case). In two cases, epistaxis occurred as a result of a saccular aneurysm located at the C₃ portion. In one case, ophthalmoplegia occurred suddenly. And in two other cases, aneurysms were incidentally discovered by angiography.
Operation was performed under normotensive, normothermic anesthesia in a half sitting position with the head lifted up by approximately 35°. In this position, it was easy to control venous bleeding from the cavernous sinus owing to reduction of venous pressure. Intraoperative monitoring was performed to evaluate cerebral blood flow (CBF), somatosensory evoked potential (SEP) and visual evoked potential (VEP).
The subtemportal approach was used for a C_4-5 AN and the pterional approach was used for C_2-3 ANs with the removal of the anterior clinoid process. Bleeding from the opened cavernous sinus was controlled with Oxycel packing. Doppler sonography was useful for checking on the patency of the internal carotid artery.
All nine aneurysms were clipped with no stenosis of the carotid artery. There was no major ischemic complication, but ipsilateral blindness (2 cases), ophthalmoplegia (1 case), transient oculomotor palsy (1 case) and transient CSF rhinorrhea (1 case) were observed.
Details of direct surgery on the nine cases of cavernous portion aneurysms are reported in this paper.

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In the present case the thrombosis of a spontaneous CCF by a combination of hypotension and radiation therapy was attemped.
The patient, a 50-year-old female, had experienced a tinnitine bruit on the left side for about six months. For one month there was also double vision and impairment of the left eye. When she was hospitalized, the bruit was inaudible but the left eye protruded with some hyperemia and edema. There was double vision in every direction except for straight ahead. The CCF was revealed only in the left internal carotid angiogram. The arteriovenous shunt showed relative high flow and pressure. When the systemic blood pressure was decreased by the hypotensive drugs, the bruit became weak and transient. The radiation therapy was commenced, and after 2000 rads, the CCF had decreased in size. The radiation therapy was finished at a total dosage of 3600 rads. On the patient's discharge from the hospital, some visual impairment remained, so hypotensive drugs were continued. The symptoms gradually improved. It was confirmed by the angiography one year that the CCF had completely disappeared, and there was no recurrence in the ensuing 12 months.
We wish to emphasize that the decrease of systemic blood pressure brings a decrease of pressure and flow of the shunt with consequent thrombosis. This is a new method for the treatment of small vascular anomalies.

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Surgical techniques for a combined infratemporal epidural and medial triangle approach to basilar tip aneurysms consists of 1) an orbitozygomatic frontotemporal craniotomy, 2) an infratemporal epidural approach in order to expose the nerve sheathes of the IInd and Ist divisions of the trigeminal nerve and the medial half of the gasserian ganglion, 3) a pterional transsylvian approach for opening the superior wall of the cavernous sinus via the medial triangle and 4) unveiling the cavernous sinus medial to the IInd division of the trigeminal nerve.
Seventeen cases of ruptured basilar tip aneurysms which were operated on via this orbitozygomatic infratemporal transcavernous approach were divided into three groups and the clinical features were reviewed. The fact that out of 4 cases in the early-operation group only one case showed good operative result seems to be attributed to the serious original Hunt and Kosnik Grade of the patients. All 3 cases with Hunt and Kosnik Grades I and II in the relatively early-stage operation group (operated on between Day 6 and Day 10) were good postoperatively. The operative result of 6 out of 8 cases with Grade I or II in the delayed-operation group was good. Conclusion: 1. This transcavernous approach seems to be the preferable approach to the basilar tip aneurysm in the early stage, with several advantages such as 1) wide exposure of the operative field, 2) the shortest possible distance with only slight retraction of the temporal tip with its dura mater, and 3) no division of the Sylvian vein and the spheno-parietal sinus running within the temporal dura propria. 2. Clipping of the basilar tip aneurysm being located either in higher or lower position can be performed successfully without retracting the carotid artery and its tributaries.

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