Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, Florida 33136, USA.
J Neurosurg. 2011 Jan;114(1):129-32. doi: 10.3171/2010.1.JNS091433. Epub 2010 Feb 5.
The treatment of indirect carotid cavernous fistulas (CCFs) is challenging and primarily accomplished by endovascular means utilizing a variety of embolic agents. Transvenous access to the cavernous sinus is the preferred method of embolizaiton of indirect CCFs as they are frequently associated with numerous small-caliber meningeal branches. Although the inferior petrosal sinus is the simplest, shortest, and most commonly used venous route to the cavernous sinus, the superior ophthalmic vein, superior petrosal sinus, basilar plexus, and pterygoid plexus present other endovenous options. Occasionally, however, use of these venous routes may not be possible due to vessel tortuosity or sinus thrombosis and occlusion. The authors report a case of an indirect CCF that could not be treated endovascularly due to inability to access the cavernous sinus via a transfemoral transvenous approach. Angiography revealed a small, deeply located superior ophthalmic vein that was thought to be suboptimal for a direct cutdown. The cavernous sinus was cannulated directly via a transorbital approach using fluoroscopic guidance with a 3D skull reconstruction overlay. The fistula was subsequently obliterated using ethylene vinyl alcohol copolymer (Onyx). The technique and advantages of both 3D osseous reconstruction as well as Onyx embolization are discussed.
间接颈动脉海绵窦瘘（CCF）的治疗具有挑战性，主要通过血管内途径利用各种栓塞剂来完成。由于间接 CCF 常伴有许多小口径脑膜分支，因此经静脉入路至海绵窦是栓塞的首选方法。尽管下岩窦是最简单、最短、最常用的通往海绵窦的静脉途径，但眼上静脉、岩上窦、基底丛和翼丛也提供了其他的静脉入路选择。然而，由于血管迂曲或窦血栓形成和闭塞，这些静脉途径有时可能无法使用。作者报告了一例间接 CCF 病例，由于无法通过经股静脉入路进入海绵窦，因此无法进行血管内治疗。血管造影显示一条小而位置深的眼上静脉，认为直接切开不太理想。在透视引导下使用 3D 颅骨重建叠加，直接经眶内入路对海绵窦进行了穿刺。随后使用乙烯-乙烯醇共聚物（Onyx）闭塞瘘口。讨论了 3D 骨重建和 Onyx 栓塞的技术和优点。
