Abstract
BACKGROUNDAccess of the cavernous sinus (CS) via venous route from the inferior petrosal sinus (IPS) can sometimes be challenging during the treatment of carotid cavernous fistulas (CCF), largely because of anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection.OBSERVATIONSA 58-year-old male was transferred to our university hospital center after suspected diagnosis of CCF at another hospital by head computerized tomography-angiogram. His symptoms included three weeks of right eye pain that was later complicated by redness, diplopia, and blurry vision. In a diagnostic angiogram, separate contrast injections from the arterial side via internal carotid artery (ICA) and from the venous side via IPS did not reveal a connection point. Injecting contrast simultaneously from both arterial and venous ends resulted in visualization of a connection point allowing entry into the CS.LESSONSTechnique of simultaneous contrast injection from ICA and internal jugular vein is comparatively simple and saves an operator prolonged time and complexity of approach. In our case, it revealed fistulous point allowing navigation and completing the coiling.
Highlights
Access of the cavernous sinus (CS) via venous route from the inferior petrosal sinus (IPS) can sometimes be challenging during the treatment of carotid cavernous fistulas (CCF), largely because of anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection
Accessing the cavernous sinus (CS) via the venous route from the inferior petrosal sinus (IPS) is the favored approach given the shortest course of IPS via low pressure internal jugular vein (IJV).[1]
CCFs are classified into traumatic versus spontaneous based on etiology, high flow versus low flow based on hemodynamics, and direct versus indirect based on the angioarchitecture.[1,2]
Summary
Access of the cavernous sinus (CS) via venous route from the inferior petrosal sinus (IPS) can sometimes be challenging during the treatment of carotid cavernous fistulas (CCF), largely because of anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection. LESSONS Technique of simultaneous contrast injection from ICA and internal jugular vein is comparatively simple and saves an operator prolonged time and complexity of approach. In our case, it revealed fistulous point allowing navigation and completing the coiling. Accessing the cavernous sinus (CS) via the venous route from the inferior petrosal sinus (IPS) is the favored approach given the shortest course of IPS via low pressure internal jugular vein (IJV).[1] A major hurdle in accessing the IPS is the fast transit of contrast via fistulous point secondary to high pressure from arterial end. The aim of this article is to report a technique of simultaneously injecting contrast from arterial system via the internal carotid artery (ICA) and venous system via IPS opacifying the connection point and allowing navigation into the IPS
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