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|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 4 | Page : 606-607
Multimodal management of a complex indirect carotid cavernous fistula
Mohamed A Deniwar1, Sudheer Ambekar2, Mohammed Samy A Elhammady2
1 Department of Neurological Surgery, Faculty of Medicine, University of Mansoura, Egypt
2 Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33136, USA
|Date of Web Publication||4-Aug-2015|
Mohammed Samy A Elhammady
Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33136
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Deniwar MA, Ambekar S, Elhammady MA. Multimodal management of a complex indirect carotid cavernous fistula. Neurol India 2015;63:606-7
Endovascular management is the first line of treatment of most carotid cavernous fistulas (CCFs).  Rarely, direct puncture of the cavernous sinus (CS) may be needed to completely obliterate the fistula when all the other endovascular routes are not available.
A 62-year-old woman underwent a transvenous embolization of an indirect CCF. A retrograde angiogram revealed a hypoplastic left inferior petrosal sinus (IPS) that could not be catheterized. Access to CS via the superior ophthalmic vein (SOV) was not feasible as it did not communicate with the facial vein. The CS was coiled via the right IPS. The final angiogram revealed near occlusion of the fistula with delayed filling of the SOV and absence of cortical venous reflux [Figure 1]a-d. However, a 1-month follow-up angiogram revealed persistence of the fistula with the reappearance of cortical venous drainage. Another attempt at embolization via the superior petrosal sinus failed due to inability to access the CS. The SOV approach was not feasible as the SOV did not reach the eyelid. Finally, the CS was exposed using a frontotemporal craniotomy. The lateral wall of the CS was then punctured directly and catheterized with a 4F microsheath. Coils were subsequently deployed within the CS through an SL-10 microcatheter [Figure 2]. Complete obliteration of the CCF was confirmed with an intraoperative angiography. A 2 month follow-up angiogram revealed complete obliteration of the left CCF [Figure 1]. At a 10 month follow-up, the patient' symptoms had completely resolved.
|Figure 1: Anteroposterior left internal carotid artery (a) and external carotid artery (b) digital subtraction angiogram views demonstrating the indirect carotid cavernous fistula (CCF). Antero - posterior (c) and lateral (d) views of the left internal carotid artery digital subtraction angiogram demonstrating complete occlusion of the CCF|
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|Figure 2: Intraoperative images (2a and b) showing the exposure of cavernous sinus (CS) and clipping of the abnormal fistulous veins draining into the CS|
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Surgical exposure of the targeted artery or vein has been reported to allow an endovascular access to the CS. , Surgical exposure of the CS for endovascular coiling has been reported in two cases so far. , Krisht et al., described a pretemporal approach to expose the CS; while, Guerrero et al., exposed the CS using a cranio-orbitozygomatic approach. In our case, all endovascular transvenous options were unavailable. Finally, we performed a frontotemporal craniotomy to puncture and subsequently coil the CS under direct vision. One caveat to observe during endovascular embolization of CCF is that the coiling should begin at the point where the SOV enters the CS. Subsequent coils should be used to close the fistula. Obliteration of SOV drainage is essential to complete obliteration of the fistula. In our case, the fact that there was persistent early filling of the SOV at the end of the previous embolization had led to recurrence of the fistula.
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[Figure 1], [Figure 2]