title: Combined transarterial, transvenous, and direct puncture of the cavernous sinus to cure a traumatic carotid cavernous fistula.
abstract: Direct carotid cavernous fistulas (CCF) are generally well managed by simple endovascular treatment. We report an 8-year-old boy who required subsequent direct puncture of the cavernous sinus to completely obliterate the residual fistula after both transarterial and transvenous embolization had been performed. He presented with a mild right frontal headache, congestion of the right conjunctiva, blurred vision, and photophobia. Cerebral angiography demonstrated a right direct CCF. The patient underwent transarterial and transvenous embolization of the cavernous sinus (CS) with Gugliemi detached coils (GDCs), but a residual shunt persisted. Two days later, another session of embolization by direct puncture of the CS with GDCs was performed after failure to navigate through the superior ophthalmic vein which was partially occupied by previously deployed coils. Immediate control angiography showed complete obliteration of the fistula and the patient's symptoms rapidly resolved. This is the first report of a patient with a CCF who required three combined approaches - transarterial, transvenous, and direct puncture of the CS - to achieve complete closure of the complexed shunt.
authors.affiliation: Department of Medical Imaging, Far Eastern Memorial Hospital, No. 21, Nan-Ya South Road, Sec 2, Pan-Chiao City, 220, Taiwan. bcjlin@gmail.com
authors.forename: Chung-Jung
authors.initials: CJ
authors.lastname: Lin
authors.forename: Chao-Bao
authors.initials: CB
authors.lastname: Luo
authors.forename: Feng-Chi
authors.initials: FC
authors.lastname: Chang
authors.forename: Michael Mu-Huo
authors.initials: MM
authors.lastname: Teng
authors.forename: Kao-Lun
authors.initials: KL
authors.lastname: Wang
authors.forename: Shu-Hsun
authors.initials: SH
authors.lastname: Chu
mesh_terms: D002339:Carotid Arteries / Q000000981:diagnostic imaging / Q000601:surgery; D020216:Carotid-Cavernous Sinus Fistula / Q000000981:diagnostic imaging / Q000628:therapy*; D002426:Cavernous Sinus / Q000000981:diagnostic imaging / Q000601:surgery; D002533:Cerebral Angiography / Q000379:methods; D002648:Child; D017023:Coronary Angiography / Q000379:methods; D004621:Embolization, Therapeutic; D005471:Fluoroscopy / Q000379:methods; D006801:Humans; D008297:Male; D011677:Punctures / Q000379:methods