Endoscope-assisted transsphenoidal puncture of the cavernous sinus for embolization of carotid-cavernous fistula in a neurosurgical hybrid operating suite

Abstract

Endovascular embolization is the treatment of choice for carotid-cavernous fistulas (CCFs), but failure to catheterize the cavernous sinus may occur as a result of vessel tortuosity, hypoplasia, or stenosis. In addition to conventional transvenous or transarterial routes, alternative approaches should be considered. The authors present a case in which a straightforward route to the CCF was accessed via transsphenoidal puncture of the cavernous sinus in a neurosurgical hybrid operating suite. This 82-year-old man presented with severe chemosis and proptosis of the right eye. Digital subtraction angiography revealed a Type B CCF with a feeding artery arising from the meningohypophyseal trunk of the right cavernous segment of the internal carotid artery. The CCF drained through a thrombosed right superior ophthalmic vein that ended deep in the orbit; there were no patent sinuses or venous plexuses connecting to the CCF. An endoscope-assisted transsphenoidal puncture created direct access to the nidus for embolization. Embolic agents were deployed through the puncture needle to achieve complete obliteration. Endoscope-assisted transsphenoidal puncture of the cavernous sinus is a feasible alternative to treat difficult-to-access CCFs in a neurosurgical hybrid operating suite.

Transvenous embolization of a direct carotid-cavernous fistula through the pterygoid plexus approach

“…Tang et al. [10] reported an indirect CCF treated using endoscope-assisted transsphenoidal puncture of CS for embolization. However, because of the invasiveness and the need for a hybrid operating room, we elected to navigate microcatheter through the retromandibular vein, maxillary vein, pterygoid plexus, and emissary vein into the CS for embolization.…”

Usefulness of an Electromagnetic Navigation System for Direct Percutaneous Puncture of the Superior Ophthalmic Vein

“…the angular vein, are present, making transfemoral/-venous approaches difficult in many cases. 3,4) Previously, a microcatheter was inserted into the angular vein through a minor incision, but this was relatively invasive, being a disadvantage. Furthermore, an approximately 10-mm incision was required in many cases, being esthetically disadvantageous.…”

“…1,2) Tang reported that neurological complications were observed in 4 of 20 patients in whom TVE was performed via the IPS with thrombosis-related occlusion, and the mean IPS approach time was 111 minutes. 3) In many patients with IPS occlusion, the SOV functions as a main drainage vein. The SOV itself is markedly swollen, but tortuosity/stenosis of the peripheral veins, such as sulcus on the body surface, and the mean vascular diameter is reportedly 2.2 mm.…”

Endovascular Approaches to the Cavernous Sinus in the Setting of Dural Arteriovenous Fistula

“…Ghosh et al described a patient who underwent image-guided burr hole placement to allow catheterization of the Sylvian vein and subsequently access the CS and then embolize the patient’s CCF [ 31 ]. Endoscopic-assisted transsphenoidal access to the CS for CCF treatment has also been described [ 32 ]. These approaches, and more, highlight the creativity of the endovascular surgeon and the multitude of options available.…”