Carotid cavernous sinus fistulas not approachabel by traditional transarterial
1. Coil implantation via superior and inferior ophthalmic vein
2. Embolisation via craniotomy
J. Schmidbauer1, M. Voges2, K. Schwerdtfeger3,T. Hagen2, K. W. Ruprecht1
Introduction: Carotid sinus cavernous fistula is an arteriovenous shunt between the internal or external carotid artery and the cavernous sinus. Based on clinical and angiographic differences, this entity has been further classified in traumatic (direct, high flow) and spontaneous (indirect, low flow, dural). Without treatment severe complications like episcleral secondary glaucoma, central vein occlusion or exudative retinal detachment may occur. Traditional therapy is the transarterial approach by an interventional neuroradiologist. Seldom such a approach is not possible due to anatomic conditions. We report on four patients in such a situation.
Patients and methods: Two patients underwent anterior orbitotomy via sub brow incision with cannulation of the superior ophthalmic vein (pat. 1) and the inferior ophthalmic vein (pat. 2) and embolization of the cavernous sinus with platinum coils. In two further patients (pat. 3 and 4) this approach was not possible because of to small lumina of the ophthalmic veins. A craniotomy with preparation of the deep sylvian vein and particle embolisation was performed.
Results: In all four patients the fistulas were sufficiently treated by clinical and angiographic follow up.
Discussion: In interventional transarterial non treatable arteriovenous fistulas the reported methods may work as an ultima ratio. When performed by an interdisciplinary team (orbital surgeon, neurosurgeon, neuroradiologist) it is a technically straightforward and effective treatment.
1Eye Hospital, 2Department of Neuroradiology, 3Department of Neurosurgery, University of Saarland, D - 66421 Homburg/Saar