Cavernous Sinus Dural Arterial Venous Fistula – Facial ... · sinus dural arteriovenous fistula...
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INTERVENTIONAL NEURORADIOLOGY 24/7 Contact & Appointment (310) 267-8761 or 8762 Cavernous Sinus Dural Arterial Venous Fistula – Facial Transvenous Approach DIVISION OF INTERVENTIONAL NEURORADIOLOGY Presents a patient case treated by the team members of the division and physicians and staff of the UCLA Comprehensive Stroke Center GARY DUCKWILER, MD Director and Professor FERNANDO VINUELA, MD Professor Emeritus REZA JAHAN, MD Professor SATOSHI TATESHIMA, MD, DMSc Associate Professor NESTOR GONZALEZ, MD Associate Professor VIKTOR SZEDER, MD, PhD Assistant Professor PATIENT PRESENTATION Figure 1A: Ap right carotid showing filling from right to left cavernous sinus (arrow) and superior ophthalmic vein (SOV) on left (large arrow). • A 54-year-old female with a history of originally right eye chemosis and proptosis with diplopia who then developed left eye chemosis and proptosis. She still has diplopia as well as some mild decreased visual acuity. On exam there is a left nerve VI palsy. Diagnosis of left cavernous sinus dural arteriovenous fistula was made on clinical and imaging evaluation. TREATMENT PLANNING • As the symptoms were significant and worsening, treatment was indicated. This worsening is often precipitated by clotting of the outlet veins (the superior ophthalmic vein (SOV) in her case). • The clotting does make it harder to get to the site of the fistula in the cavernous sinus. However with a small but patent outlet to the facial vein, it was elected to approach from this difficult route. Figure 1B: lateral view with arrow showing cavernous sinus (site of fistula), and large arrow showing superior ophthalmic vein. (over) Figure 2: catheterization from femoral vein to jugular to facial vein to angular vein of face for access to SOV. Arrow shows microcatheter tip. Small arrows outline medial orbit.
Transcript of Cavernous Sinus Dural Arterial Venous Fistula – Facial ... · sinus dural arteriovenous fistula...
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.
