Cavernous Sinus Dural Fistula Research Articles

Transvenous embolization of dural arteriovenous fistula of the cavernous sinus by identifying the orifice of the occluded inferior petrosal sinus through the angle of the microguidewire

ObjectiveTo describe that the angle of the microguidwire on lateral projection under fluoroscopic image is a prediction of cannulation of the occluded inferior petrosal sinus in the transvenous embolization of cavernous sinus dural fistulas. MethodsFrom January 2018 through January 2021, 12 cavernous sinus dural fistulas with ipsilateral inferior petrosal sinus occlusion identified in 12 consecutive patients were cured by cannulation of the occluded ipsilateral inferior petrosal sinus. Clinical, radiologic and procedure data of the 12 patients were retrospectively reviewed. The angle of microguidewire between on lateral projection under fluoroscopic image between the inferior petrosal sinus and the internal jugular vein was measured. ResultsIn the 12 patients, access via the occluded ipsilateral inferior petrosal sinus was primarily attempted as the transvenous approach. During the procedure, the angle of microguidwire on lateral projection under fluoroscopic image between the inferior petrosal sinus and the internal jugular vein was 117°±7°, which is very useful to confirm the cannulation of the occluded inferior petrosal sinus. Complete occlusion was achieved in all fistulas, with no procedure-related morbidity or mortality. Postprocedural symptom was improved in all patients. ConclusionCannulation of an occluded inferior petrosal sinus is possible and reasonable as an initial access attempt for cavernous sinus dural fistulas. The angle of microguidwire on the lateral projection under fluoroscopic image can help to confirm the orifice of the occluded inferior petrosal sinus.

Anatomical localization of the cavernous sinus dural fistula by 3D rotational angiography with emphasis on clinical and therapeutic implications

Background and purposeCarotid cavernous sinus dural arteriovenous fistulas (CSDAVFs) are presumed to be located within the walls of the cavernous sinus, however the exact fistulous site has not yet been studied by angiographic or anatomical methods. The present study aimed to localize CSDAVFs with the help of 3D rotational angiography (RA) and correlated the observations with clinical and angiographic findings. Materials and methodsThe CSDAVFs were categorized as dural, extradural or osseous based on the site of convergence of feeders into the venous sac. Extradural CSDAVFs were further subcategorized into posteromedial, posterolateral and anterior subtypes, depending on proximity to a possible venous plexus. This classification was correlated with various clinical presentations and angiographic subtypes. ResultsThirty-seven patients were included in the final analysis. The sac was identified in all the patients and the mean sac size of the fistula was small (<4mm). Dural type was associated with exclusive cortical venous drainage. Extradural anterior CSDAVF showed tendency towards younger age predilection. Extradural posterolateral CSDAVF was more often associated with initial oculomotor nerve palsy and this observation was statistically significant. Discordancy between the location of the fistula and the side of clinical affection was observed in midline fistulas such as osseous CSDAVF and posteromedial type of extradural CSDAVF. ConclusionsCSDAVF is a heterogeneous vascular disorder involving the sphenoclival bone, extradural space and dura, homologous to the epidural-dural shunts of vertebra with a common clinical presentation of orbital manifestations. Preoperative localization of the fistula could explain enigmatic observations and potentially simplify its interventional management.

Orbital ultrasound in the selective screening of a dural–cavernous sinus fistula

Orbital ultrasound in the selective screening of a dural–cavernous sinus fistula

Bilateral indirect carotid cavernous fistula post trivial injury– A case report

Fifty-seven years old Malay lady, post menopausal with co-morbid of diabetes mellitus and hypertension presented with three months history of bilateral painful red eyes associated with double vision. Examination revealed both eyes proptosis, corkscrew vessels with present of bruit, secondary narrow angle with raised intraocular pressure, 6th cranial nerve palsy, and bilateral venous stasis retinopathy. CT angiogram showed bilateral dilated superior ophthalmic veins with cerebral angiogram findings of bilateral indirect carotid cavernous fistula involving small meningeal vessels. Indirect or dural cavernous sinus Fistula can easily be missed or misdiagnosed. Trivial injury especially in the predisposing patient can initiate the occurrence.

Spontaneous Isolated Dural Arteriovenous Fistula of the Cavernous Sinus: Endovascular Approach via the Foramen Ovale

The endovascular treatment of spontaneous dural cavernous sinus fistula (DAVF) can be accomplished by arterial approach, just with symptoms relief, or by numerous venous approaches through the inferior petrosal sinus, ophthalmic vein, anterior or posterior intercavernous sinus and facial vein. Our case suggests the approach to the cavernous sinus via the foramen ovale and emissary veins puncture as an alternative when there is no possibility of venous approach conventionally described. A 76-year-old woman presented with right conjunctival hyperemia, exophthalmos, intraocular pressure increasing and visual deficits in a period of six months. Angiographic diagnosis of spontaneous DAVF isolated from the cavernous sinus, Barrow Type C, with exclusive venous drainage through the superior ophthalmic vein. Endovascular treatment was performed under general anesthesia. Attempts to approach the cavernous sinus through the inferior petrosal sinus ipsilateral and contralateral intercavernous, facial vein and pterygoid plexus, as well as by dissection and direct puncture of the superior ophthalmic vein were not possible. An approach to the cavernous sinus was performed by puncturing the foramen ovale, catheterization of the emissary vein of the foramen ovale with occlusion of the fistula with microcoils. There was a symptomatic regression with gradual normalization of intraocular pressure, exophthalmos and conjunctival hyperemia in three months. The approach to the cavernous sinus through the foramen ovale and catheterization of the emissary cranial skull base vein is an exception and should be considered in cases of spontaneous and isolated DAVF not accessible by a conventional approach.

Cathétérisme de la veine ophtalmique supérieure : traitement d’une fistule durale

We report the case of a 68-year-old woman with a chronic unilateral red eye for 3 months. The ophthalmologic exam showed engorged episcleral vessels, proptosis and chemosis. Motility, visual acuity and fundus examination were normal. Neurological examination was also unremarkable. Given the subacute nature of the proptosis in association with engorged episcleral vessels, brain MRI and MRA were performed, demonstrating a right dural-cavernous sinus fistula. After two attempts via the femoral and facial veins, the dural fistula was accessed and treated via the right superior ophthalmic vein. The fistula was occluded and the symptoms regressed in 48 hours. Arteriography at 3 months confirmed a complete cure.

Surgical access on the superior ophthalmic vein to the cavernous sinus dural fistula for embolization

BackgroundDirect surgical exposure and cannulation (DSEC) of the superior ophthalmic vein (SOV) can be used as an alternative approach for the endovascular treatment of cavernous sinus dural fistulas (CSDF) that...

Transvenous Embolization of a Dural Carotid-Cavernous Sinus Fistula Via the Inferior Ophthalmic Vein

A 76-year-old woman presented with an acute onset of right periocular pain, diplopia, ocular injection, progressive proptosis, and periocular swelling. She had an unremarkable past medical history, and the erythrocyte sedimentation rate and complete blood count were normal. A carotid-cavernous sinus fistula was suspected, and an MRI demonstrated enlargement of the superior ophthalmic vein posterior to the globe and enlargement of the inferior ophthalmic vein throughout its entire course. Cerebral arteriography demonstrated a dural cavernous sinus fistula. The inferior ophthalmic vein was accessed via the inferonasal orbital space and was catheterized for delivery of multiple platinum coils to the cavernous sinus fistula. Follow-up venograms demonstrated occlusion of the fistula. At 2-month follow-up, there was a residual sixth nerve palsy and resolution of symptoms, including proptosis and periocular swelling.

Lessons Learned from Difficult or Unsuccessful Cannulations of the Superior Ophthalmic Vein in the Treatment of Cavernous Sinus Dural Fistulas

Retrograde cannulation of the superior ophthalmic vein (SOV) is an important route for embolization of cavernous sinus dural fistulas (CDF). We present our experience with technically difficult cases in which it was not possible to isolate or cannulate this vein. Retrospective, noncomparative, interventional case series. All patients diagnosed with dural CDF at the University of California Los Angeles Medical Center between January, 1993, and July, 2005, and who were treated with embolization via the SOV. The clinical records of all patients were reviewed. Patient demographics, clinical presentation, and surgical findings. Of 91 patients diagnosed with CDF during the study period, 25 patients (16 females, 9 males; mean age, 59 years) were treated with embolization via the SOV. In 6 of them (24%; 4 women and 2 men; mean age, 67 years), there were significant difficulties in cannulation of the SOV or in successful closure of the fistula with this approach. Three patients had a fragile or a very small vein that could not be cannulated, and 1 of the 3 also had a large, posteriorly located varix that bled extensively on attempted cannulation. In 2 other patients, the anterior segment of the SOV was clotted and the catheter could not be threaded. In 1 patient, an inferior location of the supraorbital vein resulted in difficulties in correct identification of the SOV. Although the SOV is a useful route for CDF embolization, the presence of fragile or clotted veins can preclude successful cannulation. Deeper orbital dissections carry a higher risk of uncontrolled bleeding and should be avoided, especially in older patients with fragile veins and those with recently diagnosed high-flow fistulas.

Transvenous Occlusion of a Dural Cavernous Sinus Fistula Using a New Expandable Hydrogel-Platinum Coil (Hydrocoil®)

Hydrogel-coated platinum coils (Hydrocoils(R)) are currently under clinical investigation for their efficacy to improve anatomic results of endovascular occlusion of cerebral aneurysms. A case is presented in which this new expandable coil type was added to bare platinum coils in order to accelerate the transvenous occlusion of a dural cavernous sinus fistula (DCSF). A 53-year-old woman presenting with mild left-sided eye redness and diplopia due to a DCSF (type D) underwent transvenous occlusion using bare platinum coils (Trufill(R)) and hydrogel coated coils (Hydrocoil(R)). After successful catherization of the cavernous sinus, bare platinum coils were densely packed and eventually combined with Hydrocoils(R) which resulted in immediate and complete occlusion of the fistula. No technical or clinical complication occurred. The new expansile hydrogel-coated platinum coil (Hydrocoil(R)) can be successfully combined with bare platinum coils to accelerate transvenous occlusion of an AV-shunting lesion. Controlled volume expansion after deployment of this device offers potential benefits for occlusion of dural arteriovenous fistulas in other locations or for parent vessel occlusions in the treatment of giant or large complex aneurysms.

Cavernous Sinus Dural Fistula Treated by Transvenous Facial Vein Approach

We report on the endovascular treatment of the spontaneous indirect dural carotid cavernous sinus type D fistula in a 60-year-old woman, in whom ipsilateral facial, angular and superior ophthalmic veins catheterization was performed to get access to the fistula site for embolization treatment. Approach via the facial vein is helpful after inferior petrosal sinus treatment failure. Although this technique requires caution in the angular vein region it allows a safe and effective treatment of these lesions. 3D rotational digital angiography can obtain more information of the angioarchitecture of the cavernous plexus and venous outflow for the catheter navigation.

Spontaneous dural cavernous sinus fistula in a child

We describe the clinical course of a 9-year-old boy in whom a spontaneous dural cavernous sinus fistula developed. The patient initially presented with proptosis and conjunctival congestion believed to be caused by a cavernous sinus hemangioma and was prescribed oral prednisone. He subsequently developed pain, increased proptosis, and decreased vision. Emergent angiography revealed a dural cavernous sinus fistula, which was successfully embolized. This is the first case to our knowledge of a dural cavernous sinus fistula in a noninfant child that was treated successfully with embolization during angiography.J AAPOS 2000;4:383-5.

Superior Ophthalmic Vein Approach for Endovascular Treatment of Dural Cavernous Sinus Fistulas

We report on our experience in surgical exposure and direct cannulation of the superior ophthalmic vein (SOV) for embolization of dural cavernous fistulas. Surgical incision of the eyelid and direct cannulation of the superior ophthalmic vein was performed in 5 patients. All patients had undergone previous attempts of arterial embolizations and/or transfemoral venous approaches which had failed to reach the fistula site. We were able to occlude the fistulas in all patients in 1 session, resulting in complete angiographic disappearance. In 1 patient surgical cannulation of the superior ophthalmic vein failured due to the specific anatomy, so that it was necessary to perform a direct puncture in the depth of the orbit. All patients showed resolution of clinical symptoms within 2 to 6 months. No complications were observed. The approach via the superior ophthalmic vein is safe and effective for endovascular occlusion of dural cavernous sinus fistulas. Particularly in patients with visual deterioration and unsuccessful on incomplete transfemoral arterial or venous embolizations it represents a valuable alternative. If catheterization of the superior ophthalmic vein is not possible, the direct puncture of the vein deep in the orbit is feasible and may be a last resort.

Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature

BACKGROUND The aim of this study is to describe the technique and results of the endovascular approach through the thrombosed inferior petrosal sinus (IPS) for occlusion of dural cavernous sinus fistulas (DCSFs). METHODS In four patients presenting with clinically symptomatic DCSFs, the angiogram did not show opacification of the IPS, indicating that it neither drained the arteriovenous fistula nor the cerebral venous outflow. A large volume biplane phlebogram of the jugular bulb was obtained to identify a thrombosed remnant of the IPS. We were able to navigate small hydrophilic catheters and microguide wires through the thrombosed IPS into the ipsi- or contralateral CS. After reaching the fistula site the CS was packed with detachable platinum coils. RESULTS We were able to reach the fistula site and to achieve a dense packing of coils within the arteriovenous shunting zone in all of the patients. The final angiogram showed subtotal or complete occlusion of the arteriovenous fistula. All four patients recovered completely and showed disappearance of the fistula on follow-up arteriograms. One patient developed a transient sixth nerve palsy. No complications related to the approach were observed. CONCLUSIONS For endovascular treatment, transvenous occlusion of DCSFs via the IPS is a feasible approach, even when this sinus is partially or completely thrombosed. Gentle handling of recently available, improved hydrophilic microguide wires and microcatheters allows effective and safe catheter navigation into the CS. A phlebogram of the jugular bulb is very useful for identification of a thrombosed IPS.

Embolization of Dural Cavernous Fistulas via Superior Ophthalmic Vein Approach

PURPOSE: To present the results of our treatment of dural cavernous sinus fistulas with surgical exposure of the superior ophthalmic vein (SOV), retrograde venous catheterization, and coil embolization of the cavernous sinus. METHODS: Twelve patients with dural cavernous sinus fistulas were treated via a retrograde transvenous SOV approach in our hospital during a 3-year period. All patients had been referred by ophthalmologists because of secondary glaucoma and decreased visual acuity. Angiography showed preferential venous drainage of the dural cavernous sinus fistulas to an enlarged ipsilateral SOV. A total of 13 SOV exposures were performed, one patient with bilateral fistulas required bilateral treatment. The vein was surgically exposed by an ophthalmologist and then catheterized. Platinum coils were delivered through a microcatheter at the fistula site and into the root of the SOV, until there was complete angiographic closure. RESULTS: Catheterization and embolization were successful in 12 of the 13 patients, with complete angiographic occlusion of the fistula. Two patients with bilateral fistulas had transient worsening of symptoms on the contralateral side. Three patients required follow-up angiography. No early complications occurred, and late complications were minor in two cases. All patients except one with long-standing symptoms recovered premorbid visual acuity. At follow-up, 11 (92%) of the 12 embolized fistulas remained occluded. CONCLUSIONS: Retrograde catheterization of the SOV and embolization of the cavernous sinus with coils is a direct, safe, and efficient way to occlude dural cavernous sinus fistulas.

Embolization Method for Cavernous Sinus Fistula within the Cavernous Sinus

The complications of dural and direct cavernous sinus fistula (CCF) arise mainly from the specific venous route. However, embolization at an inappropriate site within the cavernous sinus (CS) is also a major factor. Therefore, we first diagrammed the surrounding structures of the CS to elucidate the specificity of the venous routes. Next, we divided the inside structure of the CS into four compartments, to examine orifices at which part we can start embolization with the least danger of causing complications when we have to embolize them within the CS. We obtained findings which will be useful to prevent complications such as subarachnoid haemorrhage, glaucoma, central retinal vein thrombosis and marked neurological impairment.

Management of Cavernous Sinus-Dural Fistulas

To describe indications and surgical techniques for embolization of cavernous sinus-dural fistulas (CDF) by passing platinum coils through a cannulated superior ophthalmic vein based on our clinical experience. Retrospective clinical review. University tertiary referral hospital and eye institute. Over a 3-year period, 10 consecutive patients with CDF and progressive orbital congestion underwent transvenous embolization. All patients had a dilated superior ophthalmic vein. All 10 patients had indications for treatment of fistulas on the basis of progressive glaucoma refractory to medical management, venous stasis retinopathy with retinal ischemia, optic neuropathy, diplopia, exophthalmos with exposure keratopathy, cortical venous congestion with risk for intracranial hemorrhage, or a combination of these findings. Nine of the 10 patients underwent anterior orbitotomy via a lid-crease or sub-brow incision with cannulation of the ipsilateral superior ophthalmic vein and embolization of the cavernous sinus with platinum coils, following an unsuccessful transarterial embolization. One patient underwent a primary transvenous embolization. Successful closure of the fistula on angiography, return of baseline visual acuity, normalization of postoperative intraocular pressure, and cosmetically acceptable cutaneous scar. All 10 patients had prompt resolution of symptoms and halt of progressive visual loss following occlusion of the fistulas. Two patients had no flow in the anterior superior ophthalmic vein on angiography suggesting thrombosis, yet the superior ophthalmic vein was easily accessed in the anterior orbit, and transvenous embolization was successfully performed. In 2 additional patients with nondilated superior ophthalmic veins, we were unable to gain surgical access and in 1 case severe bleeding occurred during attempted access of the small vein. When performed by an experienced orbital surgeon and neuroradiology team, transvenous embolization of CDF via a dilated anterior superior ophthalmic vein is a technically straightforward, safe, and effective treatment for CDF and perhaps should be employed as primary therapy in cases with progressive orbital congestive symptoms. If the superior ophthalmic vein is not dilated or if it is located deep in the orbit, transorbital venous access may not be possible.

Left Dural to Right Cavernous Sinus Fistula A Case Report

Direct carotid-cavernous sinus fistulas that present with signs and symptoms contralateral to the arterial supply of the fistulas are not uncommon. We present a thoroughly documented case of a dural-cavernous sinus fistula with symptoms exclusively contralateral to the arterial source, a rarer entity. The patient presented with a red, proptotic right eye and a history of transient horizontal diplopia and a "feeling of fullness" in that eye. Magnetic resonance imaging (MRI) of the brain and orbits performed at another hospital had shown no abnormalities. Carotid angiography performed on the right side was normal; carotid angiography performed on the left side showed a dural-cavernous sinus fistula, with shunting from branches of the left external carotid artery directly to the right cavernous sinus. Orbital duplex color-flow sonography showed reverse flow in a dilated right superior ophthalmic vein. This unusual manifestation of a dural-cavernous sinus fistula offers insight into the pathophysiology of arteriovenous fistulas involving the cavernous sinus, and is a reminder that bilateral injections are required when performing carotid angiography to characterize these disorders.

Choroidal Folds and Dural Cavernous Sinus Fistula

Dural cavernous sinus fistulas may undergo spontaneous resolution with transient worsening of clinical signs and symptoms. We report such a case and document the first association of choroidal folds with this vascular malformation. Report of a Case. —A 66-year-old woman was evaluated for sudden worsening of right eye redness that had been present for 6 weeks. Visual acuity was 20/30 OD and 20/25 OS. Pupils were normal. Examination of the right eye showed 5-mm proptosis, limited supraduction and infraduction, upper and lower eyelid edema, chemosis, and dilated episcleral vessels. Results of left eye examination were normal. Intraocular pressures were 36 mm Hg OD and 16 mm Hg OS. Spontaneous venous pulsations were absent on the right, but present on the left. The fundi were otherwise normal. Computed tomography demonstrated a prominent right superior ophthalmic vein and enlargement of the right extraocular muscles. A presumptive diagnosis of dural cavernous sinus fistula