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Table of Contents    
Year : 2015  |  Volume : 63  |  Issue : 4  |  Page : 606-607

Multimodal management of a complex indirect carotid cavernous fistula

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 Publication4-Aug-2015

Correspondence Address:
Mohammed Samy A Elhammady
Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33136
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.162080

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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

How to cite this URL:
Deniwar MA, Ambekar S, Elhammady MA. Multimodal management of a complex indirect carotid cavernous fistula. Neurol India [serial online] 2015 [cited 2020 Aug 6];63:606-7. Available from:


Endovascular management is the first line of treatment of most carotid cavernous fistulas (CCFs). [1] 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. [2],[3] Surgical exposure of the CS for endovascular coiling has been reported in two cases so far. [4],[5] 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.

  References Top

Miller NR. Diagnosis and management of dural carotid-cavernous sinus fistulas. Neurosurg Focus 2007;23:E13.  Back to cited text no. 1
Heiroth HJ, Turowski B, Etminan N, Steiger HJ, Hänggi D. Coiling of a carotid cavernous sinus fistula via microsurgical venotomy: Recommendation of a combined neurosurgical and endovascular approach. J Neurointerv Surg 2013;5:e7.  Back to cited text no. 2
Tress BM, Thomson KR, Klug GL, Mee RR, Crawford B. Management of carotid-cavernous fistulas by surgery combined with interventional radiology. Report of two cases. J Neurosurg 1983;59:1076-81.  Back to cited text no. 3
Krisht AF, Burson T. Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: Technical case report. Neurosurgery 1999;44:415-8.  Back to cited text no. 4
Guerrero CA, Raja AI, Naranjo N, Krisht AF. Obliteration of carotid-cavernous fistulas using direct surgical and coil-assisted embolization: Technical case report. Neurosurgery 2006;58:E382.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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