Endoscope-assisted transsphenoidal puncture of the cavernous sinus for embolization of carotid-cavernous fistula in a neurosurgical hybrid operating suite

J Neurosurg. 2017 Aug;127(2):327-331. doi: 10.3171/2016.5.JNS16493. Epub 2016 Aug 5.

Abstract

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.

Keywords: CCF = carotid-cavernous fistula; CS = cavernous sinus; DSA = digital subtraction angiography; ECA = external carotid artery; GDC = Guglielmi Detachable Coil; ICA = internal carotid artery; NBCA = N-butyl 2-cyanoacrylate; SOV = superior ophthalmic vein; carotid-cavernous fistula; coil; embolization; endonasal; endoscope; endovascular; hybrid surgery; interventional neurosurgery; transsphenoidal approach.

Publication types

  • Case Reports

MeSH terms

  • Aged, 80 and over
  • Carotid-Cavernous Sinus Fistula / therapy*
  • Cavernous Sinus / surgery*
  • Embolization, Therapeutic / methods*
  • Humans
  • Male
  • Neuroendoscopes
  • Neurosurgical Procedures
  • Operating Rooms
  • Punctures / instrumentation
  • Punctures / methods*
  • Sphenoid Bone