[Complex carotid cavernous sinus fistulas Barrow type D: endovascular treatment via the ophthalmic vein, imaging control with standardized MRI, long-term results].
OBJECTIVE
Since feeding arteries from both the internal and external carotid artery are common, cavernous fistulas of Barrow type D are difficult to treat. Embolization using the transarterial approach is considered to be the standard therapy. However, it is often impossible to embolize feeders from the internal carotid artery. The transorbital approach after anterior orbitotomy through the ophthalmic vein is an alternative in this complex situation. The following reports our experience with three female patients who underwent transvenous embolization. Procedural success was documented using standardized MRI and clinical reevaluation.


METHODS
Three female patients between 57 and 78 years of age were diagnosed with carotid cavernous fistulas by conventional angiogram. All patients were suffering from exophthalmus and visual impairment. Two patients showed secondary glaucoma and diplopia. In one patient we performed a technically successful transarterial embolization using particles, but no relevant improvement of the patient's condition was seen. Transfemoral transvenous access via the sinus petrosus was not possible in any patient. All patients were then embolized via the ophthalmic vein using GDC detachable coils. All patients were clinically reevaluated by an ophthalmologist. Also a standardized MRI was performed for documentation. Follow-up was performed for the first patient for 32 months, for the second patient for 34 months and for the third patient for 50 months.


RESULTS
Transvenous embolization was technically successful in all three cases. Clinical symptoms disappeared rapidly. Postprocedural MRI showed a symmetric diameter of the ophthalmic vein. Venous congestion of the orbit caused by fatty tissue edema regressed completely. Contrast-enhanced magnetic resonance angiography showed normal arterial vessels without evidence of fistula.


CONCLUSIONS
Complex carotid cavernous fistulas of Barrow type D seem to be successfully treatable by embolization using the transvenous approach. Clinical symptoms seem to regress rapidly after the procedure, with diplopia being the last to regress. MRI imaging criteria for procedural success include a diameter reduction of the ophthalmic vein, a reduction of the orbital fatty tissue edema and an inconspicuous CE-MRA.
Struffert
T
T
Abteilung für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Homburg/Saar. tobias.struffert@nrad.imed.uni-erlangen.de
Grunwald
I Q
IQ
Mücke
I
I
Reith
W
W
D000368:Aged; D001159:Arterio-Arterial Fistula / Q000175:diagnosis / Q000628:therapy*; D020216:Carotid-Cavernous Sinus Fistula / Q000175:diagnosis / Q000628:therapy*; D020226:Cavernous Sinus Thrombosis / Q000175:diagnosis / Q000628:therapy*; D005260:Female; D006111:Graves Disease / Q000209:etiology; D006801:Humans; D018810:Magnetic Resonance Angiography; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D012171:Retinal Vessels / Q000473:pathology*; D016896:Treatment Outcome; D014786:Vision Disorders / Q000209:etiology; D014792:Visual Acuity