Abstract
Introduction
Carotid‐Cavernous fistulas (CC fistula) are aberrant connections between the carotid arterial system and the cavernous sinus (CS). The result is an abnormal arteriovenous shunt which can have a range of symptomatology based on involvement of neighboring neural and vascular structures within the CS. Clinically, patients can present with Dandy's triad of exophthalmos, bruit and chemosis, but often present insidiously with diplopia/visual disturbance, orbital pain or cranial nerve deficits. While cross‐sectional imaging bears high diagnostic value, cerebral angiography remains the gold‐standard for the characterization of CC fistulas. We describe a case of a Barrow Type‐D indirect CC fistula, treated endovascularly with transfacial venous approach and retrograde coil embolization of the right greater than left CS.
Case Report
A 90‐year‐old woman presented with red eyes and blurry vision. Neurological examination revealed right cranial nerve 6th palsy. MRI/MRA demonstrated marked prominence of the superior ophthalmic veins (SOV) and unusual flow related enhancement of the CS, suspect for underlying fistula. Cerebral angiogram revealed a Barrow Type‐D indirect CC fistula with arterial contribution from the proximal branches of right cavernous internal carotid artery, distal branches of right external carotid artery and distal left petrous internal carotid artery. Initially, a petrosal approach was planned. Despite recanalization attempts, both inferior petrosal sinuses were unfortunately inaccessible for access into the CS. Instead, an external jugular vein with facial and angular venous approach into the SOV was undertaken in order to access the CS in a retrograde fashion. A total of 35 platinum coils were deployed with complete packing of the right CS. Final angiographic runs of the right internal carotid artery revealed marked significant decrease in arteriovenous shunting with preservation of intracranial arterial circulation, demonstrating successful primary coil embolization of CC fistula. The patient recovered well post‐procedurally and was discharged the following day. Complete resolution of symptoms with return of visual acuity was achieved shortly after the procedure.
Discussion
Currently endovascular approach remains of primary consideration as a treatment option for both direct and indirect CC fistulas. The most common access point to the CS through the inferior petrosal sinus was unfortunately not a viable option in this case. In such circumstances, open surgical access of SOV may serve as an alternative for access to CS (albeit with potentially local or cosmetic complications). This approach illustrates an uncommon but important conduit to the CS for the practicing interventionalist, by the infrequently accessed facial and angular veins.
Disclosure
S. Shastry: None. A. Sajjad: None. K. Pittala: None. H. Nasser: None.
