INTERVENTIONAL NEURORADIOLOGY

24/7Contact&Appointment(310)267-8761or8762

Cavernous Sinus Dural Arterial Venous Fistula – Facial Transvenous Approach

DIVISIONOFINTERVENTIONALNEURORADIOLOGY

Presentsapatientcasetreatedbytheteammembersofthedivision

andphysiciansandstaffoftheUCLAComprehensiveStrokeCenter

GARYDUCKWILER,MDDirectorandProfessor

FERNANDOVINUELA,MD

ProfessorEmeritus

REZAJAHAN,MDProfessor

SATOSHITATESHIMA,MD,DMSc

AssociateProfessor

NESTORGONZALEZ,MDAssociateProfessor

VIKTORSZEDER,MD,PhD

AssistantProfessor

PATIENTPRESENTATION

Figure1A:Aprightcarotidshowingfillingfromrighttoleftcavernoussinus(arrow)andsuperiorophthalmicvein(SOV)onleft(largearrow).

• A54-year-oldfemalewithahistoryoforiginallyrighteyechemosisandproptosiswithdiplopiawhothendevelopedlefteyechemosisandproptosis.Shestillhasdiplopiaaswellassomemilddecreasedvisualacuity.OnexamthereisaleftnerveVIpalsy.Diagnosisofleftcavernoussinusduralarteriovenousfistulawasmadeonclinicalandimagingevaluation.

TREATMENTPLANNING

• Asthesymptomsweresignificantandworsening,treatmentwasindicated.Thisworseningisoftenprecipitatedbyclottingoftheoutletveins(thesuperiorophthalmicvein(SOV)inhercase).

• Theclottingdoesmakeithardertogettothesiteofthefistulainthecavernoussinus.Howeverwithasmallbutpatentoutlettothefacialvein,itwaselectedtoapproachfromthisdifficultroute.

Figure1B:lateralviewwitharrowshowingcavernoussinus(siteoffistula),andlargearrowshowingsuperiorophthalmicvein.

(over)

Figure2:catheterizationfromfemoralveintojugulartofacialveintoangularveinoffaceforaccesstoSOV.Arrowshowsmicrocathetertip.Smallarrowsoutlinemedialorbit.

INTERVENTIONAL NEURORADIOLOGY

24/7Contact&Appointment(310)267-8761or8762

ProceduresprovidedbyDINRforadultandpediatricpatients

AcuteIschemicStroke

AcuteThrombectomy/ThrombolysisExtra/IntracranialAngioplasty/Stenting

BrainHemorrhage,Aneurysm/AVM/fistulae

AneurysmcoilingStent/balloonassistedaneurysmcoilingFlowdiverterstentdeviceembolization

AVM/DuralfistulaeembolizationVenousSinusThrombectomy/Thrombolysis

Directtranscutaneousembolization

ChronicOcclusiveCerebrovascularDiseaseExtra/IntracranialAngioplasty/Stenting

VenousSinusAngioplasty/Stenting

Head/neck/orbittumors&vascularmalformations,epistaxis

EndovascularembolizationDirectpercutaneousembolization

DivisionofInterventionalNeuroradiologyDavidGeffenSchoolofMedicineatUCLARonaldReaganUCLAMedicalCenter757WestwoodPlaza,Suite2129LosAngeles,CA90095-7437http://radiology.ucla.edu/site.cfm?id=217

Figure3:usingmanualcompressiontodirectthemicrocathetertiptoSOV.

Figure4:WirebeingpassedtositeoffistulafromfemoralveintofacialveintoSOVtocavernoussinus.

Figure5A:finalapangiogramshowingfillingofcavernoussinusfistulawithembolicmaterial,curingthefistula.

PATIENTOUTCOME

• ThepatientrecoveredcompletelywithtotaleliminationofthechemosisandrecoveryoftheIVNerveandeliminationofdoublevision.Withacombinationofinternalandexternal(manualmanipulation)ofthemicrocatheter,wewereabletosuccessfullyguidethesystemtothetargetandtreatsuccessfully.

Figure5B:finallateralangiogramshowingfillingofcavernoussinusfistulawithembolicmaterial,curingthefistula.