Posterior fossa dural arteriovenous fistula presenting clinically as a carotid–cavernous fistula treated by a direct access cavernous sinus approach

Abstract

SUMMARYDural arteriovenous fistulas (dAVFs) represent approximately 10-15% of all cerebral vascular malformations. Although dAVFs can occur anywhere in the brain, they occur most frequently in the cavernous and transverse-sigmoid sinuses. Posterior fossa dAVFs presenting clinically as carotid-cavernous fistulae (CCF) are rarely encountered in clinical practice. We discuss and illustrate an unusual case of a left posterior fossa dAVF that presented clinically with chemosis and early visual impairment, similar to that of CCF. This was subsequently treated by a direct access cavernous sinus approach. We describe the technique used to access the cavernous sinus directly in cases where conventional transvenous and transarterial routes have been exhausted. BACKGROUND

Diagnosis and Minimally-Invasive Treatment of Posterior Fossa Dural Arteriovenous Fistula Presenting Clinically as A Carotid-Cavernous Fistula

“…Posterior fossa dAVF presenting with ocular congestive symptoms similar to CCF is very rare [2]. The fistula in our case was non-traumatic and spontaneously developed.…”

“…Treatment of CCF and dAVF aims to close the abnormal communication between the feeding artery/arteries and the cavernous sinus [2,5]. Therefore, the purpose of imaging is to specify the nature of the lesion, to detect arterial feeders and drainage veins, to assess its extensions various spatial plans and its effects on orbital structures and visual pathways [2,3]. Thin slices CT/MR images with time-of-flight MR angiography or CTA offer a precise depiction of these parameters [3,6].…”

“…Endovascular treatment of CCF and dAVF causes much less mortality and morbidity than open surgery [2,7]. The transvenous route, which is the safer method, should be preferred as the first-line option in endovascular treatment [8].…”

“…The transvenous route, which is the safer method, should be preferred as the first-line option in endovascular treatment [8]. Trans-arterial therapy, microsurgery or percutaneous cannulations of superior-ophthalmic-vein/petrosal-sinuses may be preferred in cases where the trans-venous approach fails [2,4,8]. Also, in selected cases, transvenous embolization may be combined with these techniques [5].…”

“…The main goal of transvenous therapy is to block the fistulous point of dAVF, rather than the entire cavernous sinus [2,9]. For this purpose, transvenous access to the cavernous sinus through the inferior petrosal sinus is most frequently used [1].…”