Integrated open surgical and endovascular embolization treatment of a paracavernous venous plexus fistula: case report

Abstract

case report J Neurosurg 122:933-938, 2015 P aracavernous venous plexus fistulas are rare types of dural arteriovenous fistulas (DAVFs) that can mimic indirect carotid-cavernous fistulas (CCFs) in both imaging characteristics and clinical presentation. While similar to CCFs, their anatomical differences lead to differences in management. Key differences include the distinct patterns of venous drainage, which affect the options for endovascular access, and the actual location of the abnormal shunt. Both types of fistula may have drainage through the superior ophthalmic vein, the plexus of the foramen ovale to the pterygoid plexus, and/or the deep middle cerebral vein. However, unlike a CCF, the paracavernous venous plexus fistula does not drain directly through the inferior petrosal sinus, but rather it drains through the cavernous sinus. Because the fistulous connection resides in the paracavernous venous plexus and not in the cavernous sinus, embolization of the cavernous sinus does not treat the fistula and can endanger the patient by altering the drainage toward cerebral veins (Fig. 1). This anatomical difference in location and venous drainage can make these types of DAVFs very difficult to treat by endovascular interventions alone.In this report the authors describe the presentation, imaging findings, and integrated open surgery and endovascular embolization of a rare type of DAVF, a paracavernous venous plexus fistula. case report History and ExaminationA 66-year-old right-handed Asian man presented with a 2-year history of persistent right eye chemosis. He was initially evaluated by an ophthalmologist who prescribed steroid eye drops, resulting in mild temporary improvement. However, the symptoms recurred and persisted. He reported right-sided occipital region headaches occurring approximately 3 times per week and mild right orbital proptosis. At presentation, he denied eye pain, recent change in his visual acuity, double vision, photophobia, nausea, and neck stiffness. On examination, he was found to have right eye chemosis, proptosis, and an orbital bruit. His right eye intraocular pressure was measured at 19 mm Hg. His visual fields were full to confrontation. Brain MRI/ MR angiography revealed mild right proptosis without obvious prominence of the right cavernous sinus or enlargement of the right superior ophthalmic vein. Cerebral angiography demonstrated an arteriovenous shunt of the right paracavernous venous plexus (Fig. 2). The fistula was fed by meningeal branches of a dilated inferolateral trunk, the right accessory meningeal artery, and the artery of the foramen rotundum. There was early filling of the left cavernous sinus across the intercavernous sinus. The venous drainage of the fistula was predominantly through the abbreviatioNs CCF = carotid-cavernous fistula; CTA = CT angiography; DAVF = dural arteriovenous fistula; ICA = internal carotid artery; LCS = laterocavernous sinus; LWSS = lesser wing of the sphenoid sinus; SMCV = superficial middle cerebral vein. The authors report the treatment ...

Endovascular Approaches to the Cavernous Sinus in the Setting of Dural Arteriovenous Fistula

“…The venous anatomy associated with the cavernous sinus can be complex and highly variable, with hypoplasia and venous thrombosis commonly seen [ 1 , 33 ]. CCF mimics, such as fistulas of the paracavernous sinus, clival plexus, laterocavernous sinus, and dura of the sphenoid wing can further complicate treatment of these DAVFs [ 29 , 34 ]. A detailed knowledge of the multiple pathways to the CS, as well as the surrounding venous anatomy, can be the difference between successful fistula obliteration and a failed attempt.…”

“…Once the lateral wall was exposed, the CS was cannulated under ultrasound guidance prior to embolization of the fistula with coils [ 28 ]. We have reported the treatment of a paracavernous venous plexus fistula with an open surgical approach combined with endovascular embolization [ 29 ]. Through a pterional craniotomy, an intradural pretemporal approach to the lateral wall of the cavernous sinus was performed.…”

Embolization of a cavernous carotid fistula through the vein of Labbé: a new alternative transvenous access route

“…The single, engorged cortical draining vein placed the patient at higher risk of intracranial hemorrhage and necessitated treatment. 3 A direct transorbital puncture of the CS 4 and a custom-tailored craniotomy and venotomy of the SMCV [5][6][7][8] are two approaches that could have resulted in access to the CS. However, both approaches are more invasive than the transfemoral, transvenous access.…”

Clinical outcomes of procedures combining endovascular embolization with a direct surgical approach in a hybrid operating room for the treatment of refractory dural arteriovenous fistulas

“…As incomplete obliteration of the dAVFs can cause recurrence, complete occlusion of the shunt points is needed to obtain favorable outcomes. [ 2 , 8 , 17 , 20 ] Recently, a surgical hybrid operating room (OR) equipped with an angiographic system has become a useful tool for the surgical treatment of vascular diseases because it can accommodate both endovascular embolization and microsurgery simultaneously. [ 4 , 5 , 12 ] To achieve complete occlusion of the AVFs, we developed a combined surgical technique of endovascular embolization and direct surgery in the hybrid OR.…”

“…[ 4 , 5 , 12 ] To achieve complete occlusion of the AVFs, we developed a combined surgical technique of endovascular embolization and direct surgery in the hybrid OR. [ 2 , 3 , 9 , 19 , 20 ] In this case series, we reviewed the clinical outcomes of refractory AVF patients who underwent procedures combining endovascular embolization and direct surgical approach and evaluated the outcome of this method.…”