Transfemoral transvenous embolization through the vein of Trolard and superficial middle cerebral vein for cavernous sinus dural arteriovenous fistula with isolated cortical vein drainage: A case report and literature review

Abstract

Background: Endovascular treatment may be challenging for cavernous sinus dural arteriovenous fistulas (CSDAVFs) with prominent leptomeningeal drainage without other accessible routes. We report a case of CSDAVF with isolated cortical venous successfully drainage treated by percutaneous transvenous embolization through the vein of Trolard and superficial middle cerebral vein (SMCV). We also review the literature of CSDAVFs treated by transvenous embolization through SMCV with or without combined surgical approach. Case Description: A 46-year-old woman presented with ocular symptoms and delayed treatment was encountered due to the COVID-19 pandemic. Cerebral angiography showed a CSDAVF (Barrow type D, Borden II, and Cognard II a + b) with isolated cortical vein drainage. Percutaneous transvenous access to the fistula through the inferior petrosal sinus was attempted but failed. Transvenous embolization through the vein of Trolard and SMCV was further attempted, and satisfactory occlusion of the fistula was achieved with detachable coils. This access route was chosen because of the occlusion of other access routes and can obliterate the need for more invasive approach, that is, combined surgical and endovascular approach. Cerebral angiography obtained 6 months following the procedure, confirmed complete angiographic obliteration of the fistula. The patient made an uneventful recovery. Conclusion: To avoid invasive combined surgical and endovascular approach, transvenous embolization through the vein of Trolard and SMCV may be another accessible option for treating CSDAVF with isolated cortical venous drainage.

Spontaneous complete regression of malignant cavernous sinus dural arteriovenous fistula following partial transarterial embolization with liquid embolic material: Report of two cases

“…[ 10 ] Following an unsuccessful approach through ipsilateral IPS, the cavernous sinus may be accessed through various routes, including contralateral IPS, SPS, facial vein, pterygoid plexus, or superficial middle cerebral vein. [ 11 ] Transorbital access by direct puncture or surgical exposure of the distal SOV is another viable option. However, this technique is the most invasive modality of embolization and carries a greater risk of procedural complications, such as orbital hemorrhage.…”

“…In general, uncured CSDVAFs after transarterial embolization required further other therapeutic modalities, including transvenous and surgical approaches. [ 1 , 2 , 11 ]…”

“…In general, uncured CSDVAFs after transarterial embolization required further other therapeutic modalities, including transvenous and surgical approaches. [1,2,11] e mechanism of further spontaneous regression of malignant CSDAVFs following partial transarterial embolization with liquid embolic material remains unclear. [4,9] After transarterial embolization, the abrupt changes in arterial flow may influence the local circulation and alter the venous drainage pattern, probably resulting in a more aggressive natural history.…”

“…At present, a transfemoral transvenous approach through the ipsilateral inferior petrosal sinus (IPS) is recommended as the first-line treatment of CSDAVFs. [ 11 ] Transarterial embolization of CSDAVFs is usually difficult and infrequently used due to small feeding branches and the risk of ischemic stroke and cranial nerve palsy. [ 7 , 16 , 17 ] If an unsuccessful transvenous approach, transarterial embolization may be considered as an alternative approach in selected patients.…”

Combined endovascular and microsurgical management of complex traumatic carotid-cavernous fistula: Three case reports

“…[12] e CS can be reached through different approaches including transarterial or transvenous route, and direct surgical exposure. [8,14,18,27,29,47,53] erefore, each technique may be considered depending on hemodynamic profile, the angioarchitecture of the fistula, feeding arteries, and venous draining veins.…”