Use of a superficial temporal vein approach for transvenous embolization of a cavernous sinus dural arteriovenous fistula: a case report

Abstract

Objective: The inferior petrosal sinus (IPS) provides the best access route to the cavernous sinus in transvenous embolization (TVE) of cavernous sinus dural arteriovenous fistula (CS-dAVF). However, some cases require other access routes. We describe a case of CS-dAVF successfully treated with TVE via the superficial temporal vein (STV) from the common femoral vein. Case presentation: The patient was an 82-year-old woman with conjunctival hyperemia and exophthalmos of the left eye due to a left CS-dAVF. A cerebral angiogram showed that the IPS had occluded and the superior ophthalmic vein, middle temporal vein (MTV), and STV had dilated as the main drainer. We had planned to reach the CS via the IPS but were forced to abandon that route because it was not possible to guide the microcatheter into the CS. We therefore attempted to use the STV for access. On the first attempt, we had difficulty in inserting the microcatheter through the tortuous section between the MTV and STV. We were able to achieve passage with manual progress by epidermal compression. Finally, we successfully guided the microcatheter to the shunted pouch and targeted embolization was performed. Conclusion: Accessing the CS via the STV can be an option when TVE via the IPS is not possible in a patient with CS-dAVF.

Cavernous sinus dural arteriovenous fistula accessed through a straightened superficial temporal vein

“…[ 12 , 20 ] It has been reported that IPS was the most selected access route to the CS and could approach the CS in 90% of patients. [ 20 ] However, when the IPS is inaccessible or it is difficult to treat the CSDAVF with TVE through the IPS route, various alternative access routes, such as the superior petrosal sinus,[ 16 ] the pterygoid plexus,[ 9 ] the facial vein (FV),[ 3 , 13 ] and the STV,[ 8 ] have been reported. The usefulness of direct puncture of the SOV,[ 2 ] FV,[ 1 , 15 ] STV,[ 11 ] and frontal vein,[ 19 ] and direct puncture of the Sylvian vein by craniotomy[ 14 ] has also been reported.…”