Department of Neurosurgery, Hospital de Clinicas "Jose de San Martin," University of Buenos Aires School of Medicine, City of Buenos Aires, Buenos Aires, Argentina.
Department of Neurosurgery, Hospital de Clinicas "Jose de San Martin," University of Buenos Aires School of Medicine, City of Buenos Aires, Buenos Aires, Argentina.
World Neurosurg. 2021 Jul;151:1. doi: 10.1016/j.wneu.2021.04.008. Epub 2021 Apr 14.
The cavernous sinus area is the second most common location for intracranial dural fistulas. Although these spontaneous dural cavernous fistulas are self-limited, a sizeable number of patients will develop progressive vision loss, diplopia, or intractable glaucoma, which warrant interventional therapy. We present the case of a 54-year-old male with hypertension and type 2 diabetes, who presented with a red right eye associated with progressive exophthalmos, ophthalmoparesis, and deterioration of visual acuity. The angiotomography showed the exophthalmos with an ingurgitated superior ophthalmic vein, with early filling in the arterial phase. A digital angiography was made, and a diagnosis of dural cavernous fistula, Barrow type D was made. Considering several transvenous approaches, alternatives included inferior petrosal sinus, access through the superior ophthalmic vein, and an open approach. In this particular case the inferior petrosal sinus was not present, so we tried to catheterize through the facial vein and also puncture the ophthalmic vein. Both procedures were unsuccessful. We decided to perform, then, an open approach with the oculoplastic surgery team (Video 1). Through an eyelid dissection, we localized the superior ophthalmic vein and then canalized it by direct visualization. With this approach, we were able to perform the cavernous sinus packing with coils and achieved a complete occlusion of the fistula. We reproduced the direct approach to the superior ophthalmic vein in a cadaveric specimen and schematized it step by step with 3-dimensional photographs..
海绵窦区是颅内硬脑膜动静脉瘘的第二常见部位。尽管这些自发性硬脑膜海绵窦瘘具有自限性，但相当数量的患者会出现进行性视力丧失、复视或难治性青光眼，需要介入治疗。我们报告了一例 54 岁男性，患有高血压和 2 型糖尿病，表现为右眼发红，伴有进行性眼球突出、眼肌麻痹和视力下降。血管造影显示眼球突出，伴有上方眼静脉的涌入，在动脉期早期充盈。进行了数字血管造影，诊断为硬脑膜海绵窦瘘，Barrow 分型 D。考虑到几种经静脉入路，替代方案包括岩下窦、经上方眼静脉入路和开放入路。在这种特殊情况下，岩下窦不存在，因此我们试图通过面静脉置管，也尝试经眶上静脉穿刺。这两种方法都没有成功。我们决定与眼整形手术团队一起进行开放入路（视频 1）。通过眼睑切开术，我们定位上方眼静脉，然后通过直接可视化进行管腔化。通过这种方法，我们能够用线圈进行海绵窦填塞，并完全闭塞瘘。我们在尸体标本上重现了经上方眼静脉的直接入路，并通过三维照片逐步对其进行了图示化。
