Elsevier

Surgical Neurology

Volume 54, Issue 1, July 2000, Pages 42-54
Surgical Neurology

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

https://doi.org/10.1016/S0090-3019(00)00260-3Get rights and content

Abstract

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.

Section snippets

Patients and methods

All four patients presented with typical symptoms, such as exophthalmus, chemosis, headaches, and cranial nerve (CN) palsies as well as decreasing vision due to increased intraocular pressure. Treatment was primarily performed via the IPS approach, although this sinus could not be visualized as the draining pathway of the fistula in any of the three patients. All fistulas were of Type D according to Barrow’s classification (1); one patient presented with cortical venous drainage. Three patients

Results

Transvenous catheter navigation through the thrombosed (nonvisualized) inferior petrosal sinus was successful in all four cases. In three patients, the ipsilateral sinus was catheterized although it was not draining the fistula and was not visualized in the late venous phase of the arteriogram. In one patient, the sinus did not drain the fistula but was shown in the contralateral late phase venogram to be draining the cerebral venous outflow. We were able to achieve a subtotal or complete

Case 1

A 71-year-old female was referred to our hospital after incomplete transarterial embolization of a dural cavernous sinus fistula at another hospital. On admission, she suffered from slight exophthalmus and chemosis of her left eye. DSA revealed a minimal residual arteriovenous shunt of the right cavernous sinus draining into the left CS and a very small left SOV, but mainly into the pial veins of the left hemisphere (Figure 1A,B). The right and left inferior petrosal sinus could not be

Discussion

Transvenous approaches frequently used in the past for endovascular occlusion of DCSFs are now the method of choice in many groups 3, 5, 8, 13, 17, 29. Depending on the type of venous drainage (anterior, posterior, cortical) and the anatomic situation, various venous routes for navigation of microcatheters into the cavernous sinus exist, including the petrosal sinuses 3, 5, 8, 13, 17, 29, the superior ophthalmic vein, the sylvian vein 5, 10, 19, 20, 22 or, as recently described, the pterygoid

Conclusion

In conclusion, the IPS approach represents the simplest and safest endovascular route to reach the cavernous sinus and should be the first choice. Nonvisualization of the IPS during angiography caused by thrombosis of the IPS does not exclude a reasonable chance of successful catheter navigation. A large volume jugular phlebogram is helpful in detecting a subtotally occluded IPS. Highly malleable hydrophilic wires and catheters minimize the risk of perforation of the IPS and of subarachnoid

Acknowledgements

We would like to acknowledge Corinna Nanyock who kindly contributed the artist’s drawing.

References (29)

  • T. Inagawa et al.

    Acute aggravation of traumatic carotid-cavernous fistula after venography through the inferior petrosal sinus

    Surg Neurol

    (1986)
  • D.L. Barrow et al.

    Classification and treatment of spontaneous carotid-cavernous sinus fistulas

    J Neurosurg

    (1985)
  • F.S. Bonelli et al.

    Venous subarachnoid hemorrhage after inferior petrosal sinus sampling for adrenocorticotropic hormone [see comments]

    AJNR Am J Neuroradiol

    (1999)
  • P. Courtheoux et al.

    Dural fistula of the cavernous sinus. Treatment through an intravenous approach apropos of 4 cases

    J Neuroradiol

    (1995)
  • Y.P. Gobin et al.

    Percutaneous transvenous embolization through the thrombosed sinus in transverse sinus dural fistula

    AJNR Am J Neuroradiol

    (1993)
  • R.A. Goldberg et al.

    Management of cavernous sinus-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein [see comments]

    Arch Ophthalmol

    (1996)
  • N. Gupta et al.

    Severe vision loss and neovascular glaucoma complicating superior ophthalmic vein approach to carotid-cavernous sinus fistula [see comments]

    Am J Ophthalmol

    (1997)
  • V.V. Halbach et al.

    Management of vascular perforations that occur during neurointerventional procedures

    Am J Neuroradiol

    (1991)
  • V.V. Halbach et al.

    Transvenous embolization of dural fistulas involving the cavernous sinus

    Am J Neuroradiol

    (1989)
  • V.V. Halbach et al.

    Transvenous embolization of direct carotid cavernous fistulas

    Am J Neuroradiol

    (1988)
  • A.M. Hanneken et al.

    Treatment of carotid-cavernous sinus fistulas using a detachable balloon catheter through the superior ophthalmic vein

    Arch Ophthalmol

    (1989)
  • K. Hasuo et al.

    Type D dural carotid-cavernous fistula. Results of combined treatment with irradiation and particulate embolization

    Acta Radiol

    (1996)
  • R. Jahan et al.

    Transvenous embolization of a dural arteriovenous fistula of the cavernous sinus through the contralateral pterygoid plexus

    Neuroradiology

    (1998)
  • W.A. King et al.

    Venous rupture during transvenous approach to a carotid-cavernous fistula. Case report

    J Neurosurg

    (1989)
  • Cited by (99)

    • Surgical management of cerebral dural arteriovenous fistulas

      2021, Cerebral Dural Arteriovenous Fistulas
    • Multimodal Management of Carotid-Cavernous Fistulas

      2020, World Neurosurgery
      Citation Excerpt :

      Given ease of navigation, the ipsilateral IPS is the preferred means of entry into the CS. However, owing to thrombosis, hypoplasia, or unfavorable venous outflow characteristics, navigation of the microcatheter into the IPS is often difficult.11 If IPS access is unavailable, we consider navigating the microcatheter through venous anastomoses between the jugular and facial veins that drain the arterialized SOV and can thus provide access to the CS.

    View all citing articles on Scopus
    View full text