Treatment of a cavernous sinus dural arteriovenous fistula by deep orbital puncture of the superior ophthalmic vein

Abstract

In a patient with progressive ophthalmological problems, including uncontrolled intraocular pressure related to a cavernous sinus dural arteriovenous fistula, urgent intervention may be necessary to prevent permanent visual loss. We report a case in which inadequate transarterial embolisation and lack of access for transvenous catheterisation, including a direct approach through the superior ophthalmic vein, preceded percutaneous puncture of the superior ophthalmic vein deep within the orbit, permitting venous occlusion without complications. This case demonstrates that deep orbital puncture of the vein is feasible for occlusion of a cavernous sinus dural arteriovenous fistula.

Transarterial and Transvenous Embolization for Cavernous Sinus Dural Arteriovenous Fistulae

“…Management of cavernous sinus DAVFs has included observation, intermittent manual compression of the ICA, stereotactic radiosurgery, transarterial or transvenous embolization and neurosurgery 8,10,11,12,14,21,27 . Endovascular techniques have become the most common treatment for patients with symptomatic cavernous sinus DAVFs that do not spontaneously resolve, because of the high rates of cure after emboliza-A B C D tion 2,6,10,14,24 . However, embolization of cavernous sinus DAVFs has been reported to cause at least temporary ophthalmoplegia in eight to 50% of patients 1,20 , and recanalization of embolized DAVFs is well documented 26 .…”

Endovascular Approaches to the Carotid Cavernous Sinus for Endovascular Treatment of Carotid Cavernous Fistulas and Hormone Sampling

“…Various kinds of venous approaches have been reported: the inferior petrosal sinus (IPS) route was the first established and most commonly used [4][5][6] , especially for venous hormone sampling 2,3 . When the ophthalmic vein [7][8][9][10][11][12][13][14][15][16][17][18][19][20] , superior petrosal sinus (SPS) 21 and pterigoid plexus (PP) 22 are involved in venous drainages of CCFs, each venous channel may become an appropriate access route. …”

“…Direct exposure may damage the superior root of the fifth nerve resulting in numbness of the forehead 17 . Furthermore, it may also cause palsy of the superior levator muscle resulting in palpebral ptosis Direct-puncture approach to the intraconal portion of the SOV has been reported in the literature 13,[15][16][17][18][19][20] . This method is a useful in cases with a dilated SOV only within the intraconal segment, according to the thrombosed branches of the SOV 17 .…”

“…However, the possibility of damage to the optic nerve, cranial nerves III-VI and ophthalmic arterial divisions needs to be taken into account. With deep-puncture (the posterior third of the SOV 17 , the posterior half of the SOV 18 , the superior orbital fissure 19 to the SOV) precise access and prevention of bleeding from the puncture point is usually difficult. Massive retro-orbital bleeding may occur and result in an untoward increase of orbital pressure 13 .…”

“…SOV, IOV approach [7][8][9][10][11][12][13][14][15][16][17][18][19][20] Approaches via direct puncture approach to the SOV and IOV and through the SOV from the dilated superficial temporal vein or division of external jugular vein are limited to CCF patients with comparative high flow drainages mainly inflowing into the SOV and/ or the inferior ophthalmic vein (IOV).…”