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

• Published in: Journal of neurosurgery Vol. 127; no. 2; p. 327
• Main Authors: Tang, Chien-Lun, Liao, Chih-Hsiang, Chen, Wen-Hsien, Shen, Shih-Chieh, Lee, Chung-Hsin, Lee, Hsu-Tung, Tsuei, Yuang-Seng
• Format: Journal Article
• Language: English
• Published: United States 01.08.2017
• Subjects: 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; coil; endonasal; interventional neurosurgery; carotid-cavernous fistula; embolization; transsphenoidal approach; ICA = internal carotid artery; NBCA = N-butyl 2-cyanoacrylate; ECA = external carotid artery; CCF = carotid-cavernous fistula; endovascular; DSA = digital subtraction angiography; CS = cavernous sinus; GDC = Guglielmi Detachable Coil; hybrid surgery; SOV = superior ophthalmic vein; endoscope
• ISSN: 1933-0693
• DOI: 10.3171/2016.5.jns16493

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.