Endovascular Embolization of a Paracavernous Arteriovenous Fistula Through a Cortical Venous Access: 2-Dimensional Operative Video.

We present the case of a 62-yr-old female with a right bulging eye and intermittent headaches. A T2 weighted magnetic resonance image revealed a dilated serpiginous vessel in the right orbit and abnormal flow voids lateral to the orbital apex. The right internal carotid contrast injection demonstrated a dural arteriovenous fistula (dAVF) fed by the ophthalmic artery and drainage into the ipsilateral superficial middle cerebral veins (SMCVs) and the basal vein of Rosenthal without opacification of the cavernous sinus. A fistulous pouch was identified anterolateral to the carotid siphon. The venous phase of the left internal carotid injection demonstrated the bilateral cavernous sinuses, suggesting no involvement of the cavernous sinus with the fistula. Concerning the risk of future hemorrhagic events, endovascular treatment was recommended. Considering the robust connection of the cortical draining vein with the superior sagittal sinus (SSS), a transvenous embolization was performed. The lesion was accessed through the SSS and the right SMCV and embolized with platinum coils, resulting in complete fistula obliteration without any complications. The SMCVs can drain into paracavernous venous structure, which independently presents lateral to cavernous sinus.1,2 Because incomplete embolization of this fistula through cavernous sinus can alter the shunt flow toward cerebral veins, we did not get into the fistula site through the cavernous sinus using conventional methods. Transvenous access through a cortical bridging vein is an efficient alternative for endovascular embolization of paracavernous dAVFs. Patient approval and consent was obtained prior to the procedure and for submission of this article.
(Copyright © 2020 by the Congress of Neurological Surgeons.)