Tag: Carotid cavernous fistula

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Endoscope-assisted transsphenoidal puncture of the cavernous sinus for embolization of carotid-cavernous fistula

J Neurosurg 127:327–331, 2017

Endovascular embolization is the treatment of choice for carotid-cavernous fistulas (CCFs), but failure to catheterize the cavernous sinus may occur as a result of vessel tortuosity, hypoplasia, or stenosis. In addition to conventional transvenous or transarterial routes, alternative approaches should be considered. The authors present a case in which a straightforward route to the CCF was accessed via transsphenoidal puncture of the cavernous sinus in a neurosurgical hybrid operating suite.

This 82-year-old man presented with severe chemosis and proptosis of the right eye. Digital subtraction angiography revealed a Type B CCF with a feeding artery arising from the meningohypophyseal trunk of the right cavernous segment of the internal carotid artery. The CCF drained through a thrombosed right superior ophthalmic vein that ended deep in the orbit; there were no patent sinuses or venous plexuses connecting to the CCF. An endoscope-assisted transsphenoidal puncture created direct access to the nidus for embolization. Embolic agents were deployed through the puncture needle to achieve complete obliteration.

Endoscope-assisted transsphenoidal puncture of the cavernous sinus is a feasible alternative to treat difficult-to-access CCFs in a neurosurgical hybrid operating suite.

 

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Venous Drainage–Based Classification System for Carotid Cavernous Fistulae

Proposal of Venous Drainage–Based Classification System for Carotid Cavernous Fistulae

Neurosurgery 77:380–385, 2015

Carotid cavernous fistulae (CCFs) are most commonly classified based on arterial supply. Symptomatology and treatment approach, however, are largely influenced by venous drainage.

OBJECTIVE: To propose an updated classification system using venous drainage.

METHODS: CCFs with posterior/inferior drainage only, posterior/inferior and anterior drainage, anterior drainage only, and retrograde drainage into cortical veins with/without other drainage channels were designated as types 1, 2, 3, and 4, respectively. CCFs involving a direct connection between the internal carotid artery and cavernous sinus were designated as type 5. This system was retrospectively applied to 29 CCF patients.

RESULTS: Our proposed classification was significantly associated with symptomatology (P , .001). Type 2 was significantly associated with coexisting ocular/orbital and cavernous symptoms only (P , .001), type 3 with ocular/orbital symptoms only (P , .01), and type 4 demonstrated cortical symptoms with/without ocular/orbital and cavernous symptoms (P , .01), respectively. There was a significant association of our classification system with the endovascular treatment approach (P , .001). Types 1 and 2 were significantly associated with endovascular treatment through the inferior petrosal sinus (P , .01). Type 3 was significantly associated with endovascular treatment through the ophthalmic vein (P , .01) and type 5 with transarterial approach (P , .01), respectively. Types 2 (27.6%) and 3 (34.5%) were most prevalent in this series, whereas type 1 was rare (6.9%), suggesting that some degree of thrombosis is present, with implications for spontaneous resolution. Type 2 CCFs demonstrated a trend toward partial resolution after endovascular treatment (P = .07).

CONCLUSION: Our proposed classification system is easily applicable in clinical practice and demonstrates correlation with symptomatology, treatment approach, and outcome.

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