Cavernous sinus dural arteriovenous fistula treated with transvenous embolization through facial vein: A case report
- Department of Neurosurgery, Saiseikai Noe Hospital, Osaka, Japan
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
- Department of Neurology, Saiseikai Noe Hospital, Osaka, Japan.
Takuto Kuwajima, Department of Neurosurgery, Saiseikai Noe Hospital, Osaka, Japan.
DOI:10.25259/SNI_455_2023Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Takuto Kuwajima1,2, Mikiya Beppu1,2, Kazuhiko Maeda3, Yoichiro Okada3, Ryuichi Kohno3, Shinichi Yoshimura2. Cavernous sinus dural arteriovenous fistula treated with transvenous embolization through facial vein: A case report. 07-Jul-2023;14:232
How to cite this URL: Takuto Kuwajima1,2, Mikiya Beppu1,2, Kazuhiko Maeda3, Yoichiro Okada3, Ryuichi Kohno3, Shinichi Yoshimura2. Cavernous sinus dural arteriovenous fistula treated with transvenous embolization through facial vein: A case report. 07-Jul-2023;14:232. Available from: https://surgicalneurologyint.com/surgicalint-articles/12398/
Background: Although the inferior petrosal sinus (IPS) is the most common approach route for transvenous embolization (TVE) of cavernous sinus dural arteriovenous fistulas (CSDAVFs), other routes should be chosen in cases which the IPS is occluded. We report a case in which the superior ophthalmic vein (SOV) approach through the facial vein (FV) was the first choice to achieve radical cure of a hemorrhage-onset CSDAVF.
Case Description: An 81-year-old female presented with a history of transarterial embolization (TAE) and TVE for the left CSDAVF 27 years ago. She was transported to us with a chief complaint of consciousness disturbance, and head computed tomography (CT) showed subcortical hemorrhage in the right frontal lobe. Cerebral angiography revealed CSDAVF with draining into the right SOV and right superficial middle cerebral vein (SMCV). Angiography, computed tomography venography, and contrast-enhanced magnetic resonance imaging did not show IPS, but the outflow pathways to the SOV, FV, and internal jugular vein were confirmed, so an approach through the FV was selected.
Conclusion: The FV was selected through the right femoral vein and thanks to the distal access catheter (DAC) being guided to the SOV, the microcatheter could be easily guided to the SMCV through the cavernous sinus (CS). TVE was performed, complete occlusion was confirmed. When preoperative occlusion of the IPS was confirmed, the FV was useful for the first choice of route, and the use of DAC allowed us to complete the treatment accurately and quickly.
Keywords: Cavernous sinus, Dural arteriovenous fistula, Endovascular treatment, Facial vein, Transvenous embolization
The inferior petrosal sinus (IPS) is the preferred approach route for transvenous embolization (TVE) of cavernous sinus dural arteriovenous fistula (CSDAVF).[
An 81-year-old female who received had undergone transarterial embolization (TAE) and TVE for the left CSDAVF 27 years ago. Postoperatively, her modified Rankin Scale (mRS) was 0. However, she had been experiencing tinnitus and ocular symptoms on the right side for several months. She was transported with consciousness disturbance (Glasgow Coma Scale: E1V1M4) and seizure, and head computed tomography (CT) [
Digital subtraction angiography (DSA) and 3D-DSA (a). On external carotid angiography, the patient was diagnosed as cavernous sinus dural arteriovenous fistula, and the arrow head shows pseudo phlebitic pattern. The arrows show feeders; a: Middle meningeal artery, b: Artery of foramen rotundum, c: Accessory meningeal artery, and d: Ascending pharyngeal artery. DSA (b). On internal carotid angiography, inferior petrosal sinus was not visualized on venous phase. (c) CT venography. Inferior petrosal vein was not detected, and the arrow shows that facial vein was well visualized.
Operative X-ray and digital subtraction angiography (DSA) (a). 7 Fr guiding catheter (arrow 1) was navigated to right internal jugular vein, and 4 Fr diagnostic catheter (arrow 2) was in right external carotid artery. Micro catheter (MC; arrow head a) and distal access catheter (DAC; arrow head b) was navigated to facial vein. MC (arrow head a) was navigated to superior middle cerebral vein superior ophthalmic vein (SOV) through, and DAC (arrow head b) was placed into SOV. DSA shows approach route, facial vein. (b) Coils which were showed in the circle were inserted, and cavernous sinus dural arteriovenous fistula was completely occluded.
IPS is the preferred approach in TVE for CSDAVF.[
One problem with this approach is that the FV is a long vessel with strong tortuosity, so it is necessary to select a catheter and connector appropriately. It has been reported that about 9% of cases drain into the external jugular vein,[
Hirayama et al.[
The draining veins of CSDAVF include SOV, SMCV, SPS, IPS, uncal vein (UV), and prepontine bridging vein (PPBV). If the FV is selected as the approach route, there is concern that if the SOV is wedged with a microcatheter during treatment, venous blood that has no outflow pathway will be drained into cortical veins such as SMCV, UV, and PPBV, or into the brainstem. If the SOV is wedged by a microcatheter during treatment, venous blood flow may drain into cortical veins such as the SMCV, UV, or PPBV, or into the brainstem. In this case, the patient had PPP due to regurgitation into the SMCV, which was the source of hemorrhage, and the first step was to embolize this outflow tract. As with all AVFs, it is very important to check for the appearance of new outflow tracts with appropriate contrast. In this case, the patient was aware of tinnitus on the affected side several months before he was sent to the emergency department, so it is possible that the tinnitus originally flowed back into the transverse or sigmoid sinus. As it gradually occluded, the IPS also occluded, and the shunt blood flow probably went to the SMCV.
Hemorrhagic CSDAVF is a very rare condition, with 6 cases (1%) out of 469 cases in JR-NET 2.[
We experienced a case of TVE through FV for CSDAVF with hemorrhage onset. If IPS obstruction is identified preoperatively, it is useful to use the FV as the first choice of route. Furthermore, the use of Guidepost for DAC in this approach is very useful for accurate treatment.
Patient’s consent not required as patient’s identity is not disclosed or compromised.
There are no conflicts of interest.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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