Spontaneous Dural Bilateral Carotid Cavernous Fistulas with Deep and Cortical Drainage (Aggressive Angiographic Features): Unilateral Transvenous Cavernous Sinus Embolization Through a Thrombosed Inferior Petrosal Sinus Using Coils and Onyx; Bilateral Fistula Resolution and Rapid Clinical Recovery

Abstract

Transvenous endovascular strategies are the first-line treatment for cavernous sinus dural arteriovenous fistulas (DAVFs). The cavernous sinus can be accessed via the inferior petrosal sinus (IPS), the superior ophthalmic, facial, superficial middle cerebral veins, or direct percutaneous puncture. The venous route usually passes through the internal jugular vein and IPS up to the pathologic shunts of the cavernous sinus. Accessing the cavernous sinus through an angiographically nonopacified IPS to address carotid-cavernous fistulas is feasible even when this sinus is thrombosed. Thus, the IPS is the most commonly used transvenous route regardless of whether there is IPS occlusion because it provides a straight and short direct route to the cavernous sinus. Modern hydrophilic microguidewires and microcatheters have improved the efficacy and safety of catheter navigation into the cavernous sinus.

Here we present our experience treating a 74-year-old female with a history of dyslipidemia and acute myeloid leukemia in remission but no known cardiovascular or cerebrovascular disease. She presented with protracted onset left “red-eye,” chemosis, diplopia, and orbital discomfort. For about 2 months, she was managed with eye drops for suspected conjunctivitis. Her red eye then intensified, and she developed proptosis and blurred vision. Increased intraocular pressure (31 mmHg) was confirmed. Cranial CT and CTA followed by MRI and MRA showed orbital congestion and venous engorgement, an enlarged left superior ophthalmic vein, and a bulging cavernous sinus. Diagnostic angiography of both internal carotid arteries (ICAs) and external carotid arteries (ECAs) revealed a left-side indirect carotid-cavernous fistula (CCF) supplied by dural branches of the left ECA (Barrow CCF Type C) and draining mainly toward the deep and cortical pial veins and secondarily through the ophthalmic venous system. The IPS was not opacified. In addition, a low-flow right-side indirect CCF supplied by dural branches of the right ICA (Barrow CCF Type B) was diagnosed. These CCFs presented signs of angiographic aggressiveness, including occlusion of the IPS, restricted outflow through the ophthalmic veins, and preferential arterialized reflux into deep and pial cerebral and cerebellar veins. Under general anesthesia, we were able to reach the cavernous shunted venous pouch via the thrombosed left IPS using a triaxial venous construct aided by stiff microguidewires, with road-mapping and radioscopic guidance. We disconnected the left arteriovenous fistula after achieving dense cavernous sinus packing using detachable coils and Onyx. No complications related to the approach were observed. The patient evolved satisfactorily with an improvement of ophthalmological signs and symptoms. She was discharged 3 days after the intervention. Follow-up MRI-MRA obtained after 2 months and angiography obtained after 3 months confirmed the persistent exclusion of the cavernous sinus and no signs of a remnant of either fistula. This case illustrates a case of bilateral indirect CCFs with aggressive angiographic features that regressed completely after single unilateral embolization carried out via a thrombosed IPS, achieving an angiographic and clinical cure.