Superior ophthalmic vein approach to carotid–cavernous fistulas

Endovascular procedures have revolutionized the treatment of carotid–cavernous fistulas through transarterial and transvenous routes. In some circumstances, however, traditional endovascular approaches may fail. Direct access to the superior ophthalmic vein (SOV) can be used to treat fistulas in this circumstance. The authors discuss the technical aspects of direct exposure of the SOV for access to the cavernous sinus.

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Management of carotid-cavernous fistulas by surgery combined with interventional radiology

Journal of Neurosurgery ◽

10.3171/jns.1983.59.6.1076 ◽

1983 ◽

Vol 59 (6) ◽

pp. 1076-1081 ◽

Cited By ~ 20

Author(s):

Brian M. Tress ◽

Kenneth R. Thomson ◽

Geoffrey L. Klug ◽

Roger R. B. Mee ◽

Bruce Crawford

Keyword(s):

Interventional Radiology ◽

Cavernous Sinus ◽

Internal Carotid ◽

Balloon Catheter ◽

Superior Ophthalmic Vein ◽

Detachable Balloon ◽

Content Type ◽

First Case ◽

Carotid Cavernous Fistulas ◽

Fine Print

✓ Two cases of carotid-cavernous fistulas were successfully treated by standard interventional radiology techniques after otherwise inaccessible vessels were surgically exposed. In the first case, an internal carotid artery (ICA), which had previously been ligated as part of an attempted surgical “entrapment” procedure, was recanalized to permit passage of a detachable balloon catheter to the fistula, resulting in its obliteration. In the second case, an enlarged superior ophthalmic vein was exposed and isolated to facilitate retrograde catheterization of the cavernous sinus and obliteration of a dural fistula between the ICA and the cavernous sinus by steel Gianturco coils. The methods and complications of both procedures are discussed.

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Bilateral superior ophthalmic vein enlargement associated with diffuse cerebral swelling

Journal of Neurosurgery ◽

10.3171/jns.1997.86.5.0893 ◽

1997 ◽

Vol 86 (5) ◽

pp. 893-897 ◽

Cited By ~ 12

Author(s):

Rohit K. Khanna ◽

Christopher J. Pham ◽

Ghaus M. Malik ◽

Eric M. Spickler ◽

Bharat Mehta ◽

...

Keyword(s):

Cavernous Sinus ◽

Sinus Thrombosis ◽

Graves Disease ◽

Retrograde Flow ◽

Cavernous Sinus Thrombosis ◽

Superior Ophthalmic Vein ◽

Content Type ◽

Carotid Cavernous Fistulas ◽

Tomography Scanning ◽

Fine Print

✓ Bilateral superior ophthalmic vein (SOV) enlargement has rarely been shown to occur in patients with septic and aseptic cavernous sinus thrombosis, Graves' disease due to obstruction of the SOV by enlarged extraocular muscles, or carotid—cavernous fistulas caused by retrograde flow. The authors describe 11 patients with bilateral SOV enlargement associated with cerebral swelling as detected by computerized tomography scanning. The bilaterally enlarged SOVs returned to a normal size following resolution of cerebral swelling and elevated intracranial pressure. To the authors' knowledge, this is the first report of bilateral SOV enlargement associated with diffuse cerebral swelling that subsequently resolved after treatment of the cerebral edema. The authors believe that the bilateral SOV enlargement was caused by mechanical cavernous sinus venous stagnation due to cerebral swelling, a syndrome that occurs more commonly than currently appreciated.

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Treatment of bilateral spontaneous dural carotid-cavernous fistulas by coils and sclerotherapy

Journal of Neurosurgery ◽

10.3171/jns.1987.66.3.0468 ◽

1987 ◽

Vol 66 (3) ◽

pp. 468-470 ◽

Cited By ~ 31

Author(s):

Patrick Courtheoux ◽

Daniel Labbe ◽

Christian Hamel ◽

Pierre-Joel Lecoq ◽

Marcio Jahara ◽

...

Keyword(s):

Intraocular Pressure ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Superior Ophthalmic Vein ◽

Content Type ◽

Steel Coils ◽

Carotid Cavernous Fistulas ◽

Fine Print

✓ A case of bilateral spontaneous carotid-cavernous fistulas producing increased intraocular pressure is reported. The fistulas lay between the meningeal branches of the internal carotid artery (ICA) and the cavernous sinus, but the ICA itself was not involved. Successful treatment was accomplished by the introduction of steel coils and a sclerotic liquid into the cavernous sinus via the distal superior ophthalmic vein.

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Onyx embolization of a carotid cavernous fistula via direct transorbital puncture

Journal of Neurosurgery ◽

10.3171/2010.1.jns091433 ◽

2011 ◽

Vol 114 (1) ◽

pp. 129-132 ◽

Cited By ~ 30

Author(s):

Mohamed Samy Elhammady ◽

Eric C. Peterson ◽

Mohammad Ali Aziz-Sultan

Keyword(s):

Cavernous Sinus ◽

Sinus Thrombosis ◽

Superior Ophthalmic Vein ◽

Carotid Cavernous Fistula ◽

Ethylene Vinyl Alcohol ◽

Embolic Agents ◽

Superior Petrosal Sinus ◽

Carotid Cavernous Fistulas ◽

Transvenous Approach ◽

Pterygoid Plexus

The treatment of indirect carotid cavernous fistulas (CCFs) is challenging and primarily accomplished by endovascular means utilizing a variety of embolic agents. Transvenous access to the cavernous sinus is the preferred method of embolizaiton of indirect CCFs as they are frequently associated with numerous small-caliber meningeal branches. Although the inferior petrosal sinus is the simplest, shortest, and most commonly used venous route to the cavernous sinus, the superior ophthalmic vein, superior petrosal sinus, basilar plexus, and pterygoid plexus present other endovenous options. Occasionally, however, use of these venous routes may not be possible due to vessel tortuosity or sinus thrombosis and occlusion. The authors report a case of an indirect CCF that could not be treated endovascularly due to inability to access the cavernous sinus via a transfemoral transvenous approach. Angiography revealed a small, deeply located superior ophthalmic vein that was thought to be suboptimal for a direct cutdown. The cavernous sinus was cannulated directly via a transorbital approach using fluoroscopic guidance with a 3D skull reconstruction overlay. The fistula was subsequently obliterated using ethylene vinyl alcohol copolymer (Onyx). The technique and advantages of both 3D osseous reconstruction as well as Onyx embolization are discussed.

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The superior ophthalmic vein approach for the treatment of carotid-cavernous fistulas: our first experience

Romanian Neurosurgery ◽

10.1515/romneu-2016-0035 ◽

2016 ◽

Vol 30 (2) ◽

pp. 230-236

Author(s):

A. Chiriac ◽

N. Dobrin ◽

Georgiana Ion ◽

V. Costan ◽

I. Poeata

Keyword(s):

Cavernous Sinus ◽

Endovascular Embolization ◽

Superior Ophthalmic Vein ◽

Technical Challenge ◽

Carotid Cavernous Sinus Fistula ◽

Alternative Routes ◽

Carotid Cavernous Fistulas ◽

Transvenous Approach

Abstract Complex cavernous sinus fistulae (CCF) are still a technical challenge to neurovascular team. The most commonly performed treatment consists in endovascular embolization of the lesion through an arterial or venous approach. Not always these conventional routes are feasible, requiring alternative routes. We report a case of a 44-year-old woman with a complex indirect (Barrow D) carotid cavernous sinus fistula treated by two interventional sessions that imposing a retrograde direct transvenous approach via the superior ophthalmic vein.

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Treatment of a carotid cavernous fistula via direct transovale cavernous sinus puncture

Journal of Neurosurgery ◽

10.3171/2013.4.jns121504 ◽

2013 ◽

Vol 119 (1) ◽

pp. 247-251 ◽

Cited By ~ 10

Author(s):

Alberto Gil ◽

Luis López-Ibor ◽

Gerardo Lopez-Flores ◽

Hugo Cuellar ◽

Eduardo Murias ◽

...

Keyword(s):

Cavernous Sinus ◽

Venous Drainage ◽

Foramen Ovale ◽

Superior Ophthalmic Vein ◽

Carotid Cavernous Fistula ◽

Cavernous Fistula ◽

Complete Obliteration ◽

Feasible Alternative ◽

Carotid Cavernous Fistulas

Endovascular treatment is the treatment of choice for indirect carotid cavernous fistulas (CCFs). Direct surgical obliteration of CCFs is recommended in highly symptomatic patients or in those with an aggressive pattern of venous drainage. However, this is a technically challenging approach associated with significant procedural morbidity. The authors present a case in which they decided to attempt a novel access to the cavernous sinus through the foramen ovale before recommending surgery for an otherwise untreatable dural CCF. This 52-year-old man with an indirect CCF and neurological deficit had undergone several attempts to embolize the shunt by means of the standard approaches. Ultimately direct cavernous sinus access was obtained through the foramen ovale, resulting in complete obliteration of the shunt. The occlusion was radiographically stable at the 6-month follow-up evaluation, and the patient has remained asymptomatic. Percutaneous transovale puncture of a CCF is a feasible alternative to accessing the cavernous sinus when traditional transvenous catheterization or direct superior ophthalmic vein approach is not possible.

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CT angiogram findings in carotid-cavernous fistulas: stratification of imaging features to help radiologists avoid misdiagnosis

Acta Radiologica ◽

10.1177/0284185119885119 ◽

2019 ◽

Vol 61 (7) ◽

pp. 945-952

Author(s):

John C Benson ◽

Charlotte Rydberg ◽

David R DeLone ◽

Matthew P Johnson ◽

Jennifer Geske ◽

...

Keyword(s):

Cavernous Sinus ◽

False Positive ◽

Phase Contrast ◽

Arterial Phase ◽

Imaging Features ◽

Superior Ophthalmic Vein ◽

Ct Angiogram ◽

Superior Petrosal Sinus ◽

Carotid Cavernous Fistulas ◽

Contrast Bolus

Background Carotid-cavernous fistulas (CCFs) are commonly misdiagnosed on computed tomography angiography (CTA). Purpose This study sought to identify the most sensitive and specific imaging features of CCFs on CTA. Material and Methods A retrospective review identified 18 consecutive patients suspected of having a CCF on CTA and subsequently underwent digital subtraction angiography (DSA). Two blinded reviewers assessed multiple findings on CTA: cavernous sinus asymmetry/enlargement; arterial-phase contrast in the cavernous sinus; proptosis; pre- or post-septal orbital edema; and dilated regional vasculature. Each was graded as positive, possible, and negative; “possible” was counted as positive. A third blinded reviewer served as a tiebreaker. Results Of 18 patients, nine were true-positive and nine were false-positive. Superior ophthalmic vein early enhancement and dilatation had 100.0% sensitivity (95% confidence interval [CI] 40.0–100.0) and 77.8% specificity (95% CI 44.4–100.0); arterial-phase contrast in the cavernous sinus had 88.9% sensitivity (95% CI 44.4–100.0) and 66.7% specificity (95% CI 18.5–90.1); peri-orbital edema had 88.9% sensitivity (95% CI 35.5–100.0) and 77.8% specificity (95% CI 22.2–100.0). The most specific markers of CCF were superior petrosal sinus and inferior ophthalmic vein dilatation/enhancement (100.0%, 95% CI 88.8–100.0 and 88.9%, 95% CI 44.4–100.0, respectively); the specificity of asymmetric cavernous enlargement was 44.4% (95% CI 11.1–77.7). Conclusions Among patients in whom a CCF is suspected on CTA, superior ophthalmic vein dilatation/enhancement and arterial-phase contrast within the cavernous sinus are the most sensitive findings. Asymmetric cavernous sinus enlargement has poor specificity and may result in false-positive diagnoses of CCFs. False positive cases were less likely to have an optimally timed contrast bolus.

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

Journal of Neurosurgery ◽

10.3171/2016.5.jns16493 ◽

2017 ◽

Vol 127 (2) ◽

pp. 327-331 ◽

Cited By ~ 2

Author(s):

Chien-Lun Tang ◽

Chih-Hsiang Liao ◽

Wen-Hsien Chen ◽

Shih-Chieh Shen ◽

Chung-Hsin Lee ◽

...

Keyword(s):

Cavernous Sinus ◽

Endovascular Embolization ◽

Direct Access ◽

Embolic Agents ◽

Complete Obliteration ◽

Feasible Alternative ◽

Alternative Approaches ◽

The Right ◽

Carotid Cavernous Fistulas ◽

Operating Suite

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.

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