title: Transorbital direct puncture of the posterior cavernous sinus through the internal carotid artery for embolization of isolated cavernous sinus dural arteriovenous fistula.
abstract: BACKGROUND
  Most cavernous sinus dural arteriovenous fistulas (CSDAVFs) present with benign ocular symptoms; isolated CSDAVFs with aggressive behavior are extremely rare. The treatment goal is to occlude the fistula totally. However, transarterial or venous access may not be possible because of complex angioarchitecture.
  
  
  METHODS
  A woman in her late 70s presented with progressive respiratory failure and rapid deterioration of limb muscle power. Imaging studies showed an isolated CSDAVF with exclusive venous drainage to the deep venous system leading to venous hypertension as well as ischemic changes in the brain stem, left thalamus and basal ganglia. Transvascular access of the cavernous sinus (CS) failed. The fistula was eventually occluded by transorbital direct puncture of the posterior CS through the internal carotid artery (ICA) with coils delivered into the CS. The holes in the walls of the ICA created by the puncture needle were sealed by detachable coils and the patient was discharged with mild paresis.
  
  
  CONCLUSIONS
  Although more invasive than the transvascular route and possibly associated with the risk of loss of visual acuity and occurrence of subarachnoid hemorrhage, transorbital direct puncture of the posterior CS through the ICA is an alternative and feasible method to treat isolated aggressive CSDAVFs when access by the transvascular route fails.
authors.affiliation: Department of Radiology, Taipei Veterans General Hospital, School of Medicine, National Yang Ming University, Taipei, Taiwan, Republic of China. cbluo@vghtpe.gov.tw
authors.forename: Chao-Bao
authors.initials: CB
authors.lastname: Luo
authors.forename: Michael M H
authors.initials: MM
authors.lastname: Teng
authors.forename: Feng-Chi
authors.initials: FC
authors.lastname: Chang
authors.forename: Wan-Yuo
authors.initials: WY
authors.lastname: Guo
authors.forename: Cheng-Yen
authors.initials: CY
authors.lastname: Chang
mesh_terms: D000368:Aged; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging*; D020216:Carotid-Cavernous Sinus Fistula / Q000000981:diagnostic imaging* / Q000628:therapy; D002404:Catheterization / Q000295:instrumentation / Q000379:methods; D002426:Cavernous Sinus / Q000000981:diagnostic imaging*; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging* / Q000628:therapy; D004621:Embolization, Therapeutic / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D009915:Orbit / Q000000981:diagnostic imaging; D011677:Punctures / Q000295:instrumentation / Q000379:methods*; D011859:Radiography