EndovascularTransvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature
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.
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2020, World NeurosurgeryCitation 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.