Endovascular embolization is the treatment of choice for Carotid-Cavernous Fistulas (CCFs), but rarely catheterization of the cavernous sinus via venous or arterial pathway is not possible. The authors present one of such cases in which a straightforward route to the CCF. The route was accessed via endoscopic trans-spheroidal puncture of the cavernous sinus with aseptic procedure.
This 58-year-old woman presented with chemosis of left eye and left frontal excruciating headache. Digital Subtraction Angiography (DSA) revealed a Type D CCF. Regurgitation of left superior ophthalmic vein and cortical veins were noted. There were no patent sinuses or venous plexuses connecting to the CCF except for the right inferior petrosal sinus. The CCF could not be embolized with a trans-venous approach, we therefore created a direct access to the CCF with an endoscope-assisted transsphenoidal puncture. Embolic agents were deployed through the puncture needle to achieve complete obliteration. Endoscope-assisted transsphenoidal puncture of the cavernous sinus is a feasible alternative to treat difficult-to-access CCFs. For concern risk of infection, we present a relative aseptic “double sheath” technique to access to CCF via endoscopic transsphenoidal approach.
Carotid-cavernous fistula; Embolization; Endonasal; Endoscope; Endovascular; Trans-sphenoidal approach.