Superior Ophthalmic Vein Access for Embolization of an Indirect Carotid Cavernous Fistula

Abstract

Carotid cavernous fistulae (CCF) are defined as abnormal connections between the carotid circulation and cavernous sinus. CCFs can be categorized as being direct or indirect. Direct CCFs are usually associated with trauma, whereas indirect CCFs are associated with revascularization following cavernous sinus thrombosis. We present a case of a 53-year-old male who presented with tinnitus, proptosis, conjunctivitis, and blurry vision. The patient had a recent endovascular transvenous embolization that was only partially successful, with a residual carotid cavernous fistula draining to the left superior ophthalmic vein and multiple cortical veins. A physical examination of the patient showed elevated intraocular pressures bilaterally. The patient had a high-flow indirect carotid cavernous fistula with bilateral superior ophthalmic vein (SOV) and retrograde cortical vein drainage. The SOV was punctured with a micropuncture needle and was used to successfully gain access to the cavernous sinus. Multiple coils were placed in the posterior aspect of the sinus until there was complete occlusion of venous flow. Coils were packed up to the posterior aspect of the orbit near the junction of the cavernous sinus with the SOV, and the embolization was successful. Indirect CCFs have gradual onset and are usually low-flow. Low-flow CCFs might improve with medical management.Some CCFs may cause ocular manifestations and can be symptomatically managed with prism therapy or ocular patching for diplopia, lubrication for keratopathy, or topical agents for elevated intraocular pressures. However, patients presenting with persistent ocular morbidity may require surgical or endovascular intervention.

Transorbital embolization of cavernous sinus dural arterio-venous malformations with surgical exposure and catheterization of the superior ophthalmic vein

“…14 In 1988, Teng et al first described an occlusion of arteriovenous malformations of the cavernous sinus via the superior ophthalmic vein in 5 patients. 16 Over the following years, several groups described either a direct puncture 3,16,36 or a surgical exposure and catheterization of the superior ophthalmic vein 4,7,17,20,23,33,34 for endovascular treatment of indirect cavernous sinus AVMs in a limited number of patients. To our knowledge, the two largest case series describing a surgical SOV approach comparable to our technique in a cohort of n = 12 and n = 13 patients were published by Quiñones et al in 1997 33 and Goldberg et al in 1996.…”

“…For this surgical technique, only preliminary reports of a limited number of patients have been published. [2][3][4]7,11,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] Here, we analyze results from a case series of cavernous sinus dAVM patients treated at our department via this transorbital approach, with a focus on describing clinical and radiological indications, surgical technique and patient outcome, in the largest such series, to our knowledge.…”

“…Cavernous sinus arterio-venous malformations (AVFs; also referred to as carotid cavernous fistulas) are vascular malformations with an abnormal connection between branches of the internal and/or external carotid artery and the cavernous sinus [1][2][3][4] and represent approximately 12% of all cerebral arterio-venous fistulas. 1 According to the classification of Barrow et al, 5 one can differentiate between four cavernous sinus AVM subtypes: (i) direct fistulas which represent high-flow connections between the internal carotid artery and the cavernous sinus (Type A) and are often a consequence of penetrating or blunt trauma with rupture of the vessel wall; (ii) indirect (syn.…”

“…dural; dAVF), non-traumatic, low-flow fistulas (Type B-D) with a small shunt volume that are often a consequence of sinus vein thrombosis or a dilatation of pre-existing dural-arterial anstomoses. 1,2,4,[6][7][8] Dural AVMs can further be divided into three subtypes depending on the localisation of the pathological arterio-venous connection: Type B AVMs are dural shunts between the cavernous sinus and the internal carotid artery, Type C AVMs are dural shunts between the cavernous sinus and the external carotid artery and Type D AVMs show pathological connections between the cavernous sinus and both the internal and external carotid artery. 1,5 While direct cavernous sinus AVMs often show severe and acute-onset symptoms, dAVMs are more indolent and can be asymptomatic over a long time period.…”

Craniofacial Trauma and Vascular Injury

“…21 Venous access can also be performed through other veins such as the superior ophthalmic vein. [22][23][24][25][26][27][28][29][30] If the superior ophthalmic vein is dilated, the initial coils are placed at its origin from the cavernous sinus. If the cortical vein is distended, it is chosen for initial coil placement to avoid its distension and potential rupture.…”