The Superior Ophthalmic Vein Approach for the Treatment of Carotid-Cavernous Fistulas: a Novel Technique Using Onyx

Home , Cavernous sinus, Ophthalmic veins, Superior ophthalmic vein

Neurosurg Focus 32 (5):E13, 2012

The superior ophthalmic vein approach for the treatment of carotid-cavernous fistulas: a novel technique using Onyx

Nohra Chalouhi, M.D.,1 Aaron S. Dumont, M.D.,1 Stavropoula Tjoumakaris, M.D.,1 L. Fernando Gonzalez, M.D.,1 Jurij R. Bilyk, M.D.,2 Ciro Randazzo, M.D.,1 David Hasan, M.D.,3 Richard T. Dalyai, M.D.,1 Robert Rosenwasser, M.D.,1 and Pascal Jabbour, M.D.1 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience; 2Oculoplastic and Orbital Surgery Service, Wills Eye Institute, Philadelphia, Pennsylvania; and 3Department of Neurosurgery, University of Iowa, Iowa City, Iowa

Object. Endovascular therapy is the primary treatment option for carotid-cavernous fistulas (CCFs). Operative cannulation of the superior ophthalmic vein (SOV) provides a reasonable alternative route to the cavernous sinus when all transvenous and transarterial approaches have been unsuccessful. The role of the liquid embolic agent Onyx in the management of CCFs has not been well documented, especially when using an SOV approach. The purpose of this study is to assess the safety and efficacy of Onyx embolization of CCFs through a surgical cannulation of the SOV. Methods. The authors retrospectively reviewed all patients with CCFs who were treated with Onyx through an SOV approach between April 2009 and April 2011. Traditional endovascular approaches had failed in all patients. Results. A total of 10 patients were identified, 1 with a Type A CCF, 5 with a Type B CCF, and 4 with a Type D CCF. All fistulas were embolized in 1 session. Onyx was the sole embolic agent used in 7 cases and was combined with coils in 3 other cases. Complete obliteration was achieved in 8 patients and a significant reduction in fistulous flow was achieved in 2 patients, which later progressed to near-complete occlusion on angiographic follow-up. All patients experienced a complete clinical recovery with excellent cosmetic results and were free from recurrence at their latest clinical follow-up evaluations. Conclusions. Onyx embolization is an excellent therapy for CCFs in general, and through an SOV approach in particular. Direct operative cannulation of the SOV followed by Onyx embolization may be the best treatment option in patients with CCFs when all other endovascular approaches have been exhausted. (http://thejns.org/doi/abs/10.3171/2012.1.FOCUS123)

Key Words • carotid-cavernous fistula • embolization • Onyx • superior ophthalmic vein

arotid-cavernous fistulas are acquired abnormal For indirect fistulas, however, the transvenous approach communications between the cavernous sinus and is the preferred modality given the size and number of the carotid artery or its branches.20 Carotid-cav- involved arterial feeders, as well as the difficulties and ernousC fistulas are divided into 4 categories according to potential hazards associated with transarterial emboliza- the Barrow classification.2 Type A CCF is a direct shunt tion.17 In a transvenous approach, the inferior petrosal between the cavernous sinus and the ICA, whereas Types sinus is the easiest and shortest path to the cavernous B, C, and D are indirect dural fistulas with arterial feed- sinus.10 Access can also be obtained through the facial ers from the ICA, ECA, or both, respectively.2 Endovas- vein-SOV route. When all transarterial and transvenous cular therapy has become the mainstay of treatment for options have been exhausted, direct operative cannula- CCFs.10,13,19 Given the direct nature of the shunt in Type A tion of the SOV provides a direct, reasonable, and safe CCFs, transarterial embolization of the cavernous sinus route to the cavernous sinus.21,24,30 In most patient series through the fistulous site is the recommended treatment.28 that used an SOV approach, CCFs were managed primar- ily with coil embolization or detachable balloons.15,16,30 Abbreviations used in this paper: CCF = carotid-cavernous fis- Liquid embolic agents—mainly cyanoacrylate—served tula; ECA = external carotid artery; ICA = internal carotid artery; only as an adjunct to coils to achieve better obliteration IOP = intraocular pressure; SOV = superior ophthalmic vein. of the fistula.7,30

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Recently, the introduction of Onyx (ev3) has added eration of the fistula. At that time, attention is redirected an important element to the endovascular armamen- to the orbit. After removal of the access catheter, the SOV tarium and revolutionized the treatment of intracranial is ligated distal to the puncture site. With bipolar cautery, fistulas. Onyx offers several advantages over N-butyl a meticulous hemostasis is achieved, and the orbital inci- cyanoacrylate or coil embolization that allow safer and sion is subsequently closed. Follow-up angiography was better treatment of intracranial arteriovenous malforma- typically obtained in patients who showed any clinical tions and fistulas.1,4,26 However, the role of Onyx in the suspicion of recurrence of the fistula. Clinical follow-up endovascular management of CCFs has yet to be defined, evaluations were scheduled at 3 and 6 months after sur- as studies have been limited to case reports and small gery for all patients. patient series.9,27 Furthermore, the effectiveness of Onyx embolization of CCFs through a transorbital approach has not been investigated. In the present paper, we assess Results the safety and efficacy of Onyx embolization of CCFs The mean patient age in the series was 65 years, with through the SOV approach in a series of 10 patients treat- a range of 36–78 years. Eight patients were women and 2 ed at our institution. were men. The mean follow-up duration was 5.5 months (range 3–12 months). All patients had intractable orbital symptoms (Table 1). One patient had a Type A CCF, 5 had Methods a Type B, and 4 had a Type D fistula. All patients showed Study Sample some degree of dilation of the SOV, and 4 patients had CCFs that displayed bilateral arterial supply. In all these Between April 2009 and April 2011, 10 patients patients, multiple attempts to catheterize the cavernous were treated at the Jefferson Hospital for Neuroscience sinus through a transarterial or a transvenous approach for CCFs through a direct SOV approach using Onyx. had failed. In all patients, treatment of their CCFs had failed using All CCFs were obliterated in 1 session. Onyx (18 or traditional transvenous and transarterial access. Medical 34) was the sole embolic agent used in 7 cases (70%). Coils charts and angiograms were retrospectively reviewed to were deployed in addition to Onyx in 3 patients with high- determine patient characteristics, type of fistula (based on flow fistulas to achieve better obliteration and decrease the Barrow classification2), type of embolic material used, the risk of distal Onyx migration (Table 2). Complete degree of fistula occlusion after embolization, procedural obliteration of the CCF was achieved in 8 (80%) of 10 complications, clinical outcome, and angiographic fol- patients. Complete occlusion of the fistula was achieved low-up. in all 7 cases in which Onyx was used as the sole embolic agent. In 2 patients, high-flow CCFs were incompletely Operative Technique occluded after embolization but showed significant flow All procedures were performed in the angiography reduction (80%) through the fistula. Follow-up angiogra- suite under general anesthesia and continuous electrophys- phy in these 2 patients demonstrated further thrombosis iological monitoring. After femoral access is obtained and and near-complete obliteration of the fistula. In 9 (90%) a catheter placed in the carotid artery, the orbital cutdown of 10 patients, no complications were noted. One patient to expose the SOV is performed by a neuroophthalmolo- developed high IOPs in his left eye postoperatively and gist and a neurosurgeon. The orbicularis oculi muscle and was noted to have an afferent pupillary defect. This defect the orbital septum are opened following a small upper was attributed to a probable treatment-induced thrombo- eyelid crease incision. With meticulous dissection into the sis of the superior and inferior ophthalmic veins. Because superomedial orbit, the arterialized SOV is identified and the patient continued to experience high uncontrolled IOP subsequently catheterized with an 18-gauge angiocatheter despite maximum medical therapy, a cantholysis had to connected to a rotatory hemostatic valve. Under roadmap be performed to relieve orbital pressure. He subsequent- guidance, an Echelon microcatheter (ev3) is advanced into ly recovered well and was discharged on postoperative the cavernous sinus. Under full heparinization with 100 Day 3. All 10 patients in the series had a rapid clinical units/kg, the cavernous sinus is embolized using Onyx 18 recovery and demonstrated complete reversal of their or Onyx 34, depending on flow intensity across the fistula. symptoms. No signs of recurrence were noted at the latest The forward penetration of the material is closely moni- clinical follow-up evaluation in all 10 patients. Excellent tored to detect and prevent any migration into an inap- cosmetic results were achieved as well. propriate area, in which case the injection is momentarily interrupted to allow polymerization of the Onyx cast. Ex- Illustrative Case treme care is taken to maintain the patency of at least 1 of the ophthalmic veins (the superior or the inferior ophthal- This 60-year-old woman (Case 1) presented to our mic vein), because embolization of both veins leads to a institution with a 3-week history of worsening left-sided transient dramatic increase in the IOP. Coils are used only chemosis, proptosis, and diplopia. On examination, she was for high-flow fistulas to provide a framework for Onyx, found to have a sixth cranial nerve palsy with an elevated thus minimizing the risk of distal embolic material migra- IOP (28 mm Hg) in the left eye. A digital subtraction angio- tion. gram revealed a left-sided Type B CCF supplied by men- Once embolization is complete, cerebral angiograms ingeal branches of the left and right ICA with retrograde from the arterial supply are performed to confirm oblit- venous flow in the SOV and cortical veins (Fig. 1). Inferior

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TABLE 1: Patients characteristics and CCF angiographic features*

Type of Case No. Age (yrs), Sex Clinical Presentation Fistula Fistula Side Arterial Supply 1 60, F chemosis, proptosis, ophthalmoplegia (CN VI) B lt bilat ICA 2 61, F ophthalmoplegia (CN VI) D lt bilat ICA & ECA 3 70, F headaches, chemosis, ophthalmoplegia (CN III) B lt lt ICA 4 71, M chemosis, proptosis, periorbital pain B lt bilat ICA 5 56, F chemosis, proptosis B rt bilat ICA 6 36, F chemosis, proptosis A lt lt ICA 7 78, F DVA, proptosis D rt rt ICA, rt ECA 8 65, M chemosis, proptosis, ophthalmoplegia (CN III) B lt lt ICA 9 77, F DVA, ophthalmoplegia (CN III) D rt rt ICA, rt ECA 10 76, F DVA, chemosis, proptosis, ophthalmoplegia (CN VI) D lt lt ICA, lt ECA

* CN = cranial nerve; DVA = decreased visual acuity. petrosal sinuses were noted to be occluded bilaterally, and timal medical therapy, refractory ocular symptoms, and multiple attempts to catheterize the fistula through the fa- cortical venous drainage (given the potential risk of intra- cial venous system were unsuccessful. The decision was cranial bleeding).20 Access to the cavernous sinus can be made to perform a surgical cutdown to expose the SOV. obtained through the ipsilateral and contralateral inferior The vein was isolated and subsequently catheterized with petrosal sinus. Alternatively, the cavernous sinus can be an 18-gauge angiocatheter (Fig. 2). An Echelon-10 micro- approached retrograde via the facial vein, to the angular catheter was navigated into the cavernous sinus, and the vein and to the SOV.3,6,14 This approach is rarely success- fistula was subsequently embolized with 1.6 ml of Onyx ful, however, due to the tortuosity of the facial venous 18 (Fig. 3). Control angiography of the left and right ICAs system. When traditional transarterial and transvenous confirmed complete obliteration of the fistula with no evi- endovascular approaches have failed, surgical exposure dence of distal embolic material migration (Fig. 4A and B). of the SOV is an acceptable alternative.25 The SOV is a The patient’s postoperative course was uneventful and by valveless and straight vessel that is frequently dilated in the time of discharge, her IOPs had decreased to 17 mm CCFs, making it an excellent candidate for surgical expo- Hg. She displayed complete reversal of her symptoms at sure, cannulation, and endovascular navigation (Fig. 5).7 the 3- and 6-month clinical assessments and maintained In the presence of a neuroophthalmologist and an expe- complete occlusion of her fistula at the 3-month follow-up rienced neuroendovascular team, this approach is almost angiography (Fig. 4C and D). always successful in embolizing CCFs. Some investigators have even described the direct SOV approach as the 20,24 Discussion best initial treatment for all CCFs. Potential complications of this approach include infection, damage to orbital Carotid-cavernous fistulas usually present with ocu- structures, orbital hematoma, and neovascular glaucoma lar symptoms such as chemosis, proptosis, ocular bruit, (if the SOV is ligated) with subsequent loss of vision.30 loss of visual acuity, and diplopia.20 Because 20%–50% Thus far, the majority of reported cases of CCFs that were of CCFs close spontaneously, treatment is indicated only treated through an SOV approach were embolized using in the presence of visual loss, elevated IOP despite op- coils or detachable balloons.7,15,16,24,30 Quiñones et al.24 re-

TABLE 2: Complications and angiographic outcomes of the 10 patients

Type of Follow-Up Case No. Fistula Embolic Material Initial Angiographic Occlusion Complications Angiographic Occlusion 1 B Onyx 18 complete none complete 2 D Onyx 34, coils partial (80%) none near-complete 3 B Onyx 34 complete none not performed 4 B Onyx 18 complete intractable high IOP not performed 5 B Onyx 18 & 34 complete none not performed 6 A Onyx 18 complete none not performed 7 D Onyx 18 complete none not performed 8 B Onyx 18, coils complete none not performed 9 D Onyx 18 complete none not performed 10 D Onyx 34, coils partial (80%) none near-complete

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Fig. 1. Case 1. Frontal (left) and lateral (right) views of digital subtraction angiography of the left ICA demonstrating a left-sided indirect CCF (Barrow Type B). ported complete angiographic obliteration with coil embolization in 12 of 13 patients with CCFs, with complications developing in 2 patients. Derang et al.7 successfully Fig. 3. Case 1. Fluoroscopic image of the left cavernous sinus dem- treated 21 patients with balloons and coils through direct onstrating the Onyx cast. operative cannulation of the SOV and noted new cranial nerve deficits in 2 cases. (without coils). Onyx offers the advantage of filling the We used Onyx through am SOV approach for the interstices of the cavernous sinus along with small deli- treatment of 10 patients with various types of CCFs. cate fistulous channels that would otherwise be left patent Onyx was the sole embolic agent used in 7 cases and was with coil embolization. Due to its lava-like flow pattern combined with coils in 3 other cases. We were able to and its nonadhesive nature, Onyx allows longer, slower, achieve adequate obliteration of fistulas and reversal of and more controlled injections with better penetration of symptoms in all patients with a very low rate of complica- the fistula. Onyx embolization through the SOV might tions. Interestingly, all 7 cases that were embolized sole- well be the best available option in patients failing more ly with Onyx were completely obliterated at the end of traditional endovascular approaches. Impressive cosmetic the procedure. It appears that Onyx is an excellent agent results were obtained as well, given that a small incision for embolizing CCFs even when used as a monotherapy was made within the natural crease of the upper eyelid. There are very little data regarding the use of Onyx to treat CCFs. Elhammady et al.9 treated 12 patients using Onyx, 8 via a transvenous route and 4 via a transarterial route. The authors were able to obliterate all CCFs and reported 3 new cranial nerve palsies following the procedure. Lv et al.18 reported complete angiographic obliteration in 3 of 5 patients with CCFs following Onyx embolization, with cranial nerve palsies developing in 2 cases. In their series, Zaidat et al.32 used Onyx in combination with coils or stents in 5 cases and achieved complete occlusion in all 5 cases. Given that traditional endovascular approaches were used in these studies, no direct compari- son can be made with the findings of the present series. Nevertheless, the results of these studies are consistent with our findings and underline the high success rate of Onyx in the treatment of CCFs, regardless of approach. However, we could not confirm that Onyx embolization is associated with a substantial risk of new cranial nerve palsies as no such complications were noted in the present series. Investigators have postulated that Onyx induces thrombosis and swelling in the cavernous sinus, which could lead to compression of surrounding nerves.9 This Fig. 2. Case 1. Intraoperative picture of the transorbital approach, type of complication has been previously described with showing the angiographic setup with an 18-gauge angiocatheter con- coils that can exert mass effect in the cavernous sinus, nected to a rotatory hemostatic valve. leading to cranial nerve paralysis.7,21,23,24

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Fig. 4. Case 1. Digital subtraction angiograms of the left ICA. Frontal (A) and lateral (B) views show complete obliteration of the fistula following embolization with Onyx 18. Frontal (C) and lateral (D) projections at the 3-month follow-up confirm complete occlusion of the fistula.

Some authors have described treatment of CCFs Conclusions through transorbital punctures of the SOV5,31 or the cavernous sinus.8,29 In a recent article, Dashti et al.5 success- In this paper we present the results of the first case fully treated 2 patients with indirect CCFs through a series that assesses the safety and efficacy of Onyx em- direct transorbital puncture of the superior and inferior bolization of CCFs through a surgical cutdown. We were ophthalmic veins. The authors concluded that their tech- able to achieve excellent clinical and angiographic out- nique represents a reasonable alternative to cutdown pro- comes with a low rate of complications for various types cedures in most cases. We believe that a direct puncture of CCFs. Onyx can also be used efficiently as a mono- of the SOV is an unnecessarily hazardous procedure that therapy to embolize CCFs. When attempts to catheterize carries a high risk of damage to the cranial nerves, ICA, the cavernous sinus through transvenous and transarterial orbit structures, and trochlea. Furthermore, given the ar- approaches have failed, surgical exposure of the SOV fol- terialized nature of the SOV, a direct puncture of the ves- lowed by Onyx embolization (in combination with coils sel could lead to a disastrous retroorbital hematoma with when necessary) is safe and effective and should be con- the risk of vision loss. While experience with transorbital sidered the preferred treatment modality. punctures has been limited to case reports (and 1 series of 8 patients29), surgical exposure of the SOV is an es- Disclosure tablished procedure that is straightforward, safe, cosmeti- Dr. Tjoumakaris serves as a consultant to Stryker Neurovascular. cally appealing, and almost always reliable.7,11,12,20–24 Author contributions to the study and manuscript preparation

Fig. 5. Artist’s illustrations of the procedure. Left: The incision in the upper eyelid crease is shown, as well as the exposure of the dilated SOV in the superomedial quadrant of the orbit. Right: Illustration showing the relatively straight course of the SOV (arrow) draining into the cavernous sinus. The microcatheter is introduced through the SOV (A) and positioned in the cavernous sinus. Onyx is slowly injected into the cavernous sinus (B) to achieve obliteration of the fistula.

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Unauthenticated | Downloaded 09/25/21 10:10 AM UTC N. Chalouhi et al. include the following. Conception and design: Jabbour, Dumont, with low-concentration cyanoacrylate. Neuroradiology 42: Tjoumakaris, Gonzalez. Acquisition of data: Jabbour, Chalouhi, 766–770, 2000 Dumont. Analysis and interpretation of data: Jabbour, Chalouhi, 18. Lv X, Jiang C, Li Y, Wu Z: Results and complications of tran- Dumont, Tjoumakaris, Gonzalez, Bilyk, Randazzo, Dalyai. Drafting sarterial embolization of intracranial dural arteriovenous fis- the article: all authors. Critically revising the article: all authors. tulas using Onyx-18. Clinical article. J Neurosurg 109:1083– Reviewed submitted version of manuscript: all authors. Approved 1090, 2008 the final version of the manuscript on behalf of all authors: Jabbour. 19. Meyers PM, Halbach VV, Dowd CF, Lempert TE, Malek AM, Administrative/technical/material support: Jabbour, Chalouhi. Study Phatouros CC, et al: Dural carotid cavernous fistula: defini- supervision: Jabbour. tive endovascular management and long-term follow-up. Am J Ophthalmol 134:85–92, 2002 References 20. Miller NR: Diagnosis and management of dural carotid-cavernous sinus fistulas. Neurosurg Focus 23(5):E13, 2007 1. Abud TG, Nguyen A, Saint-Maurice JP, Abud DG, Bresson 21. Miller NR, Monsein LH, Debrun GM, Tamargo RJ, Nauta HJ: D, Chiumarulo L, et al: The use of onyx in different types of Treatment of carotid-cavernous sinus fistulas using a superior intracranial dural arteriovenous fistula. AJNR Am J Neuro- ophthalmic vein approach. J Neurosurg 83:838–842, 1995 radiol 32:2185–2191, 2011 22. Monsein LH, Debrun GM, Miller NR, Nauta HJ, Chazaly JR: 2. Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Treatment of dural carotid-cavernous fistulas via the superior Tindall GT: Classification and treatment of spontaneous carot- ophthalmic vein. AJNR Am J Neuroradiol 12:435–439, 1991 id-cavernous sinus fistulas. J Neurosurg 62:248–256, 1985 23. Oishi H, Arai H, Sato K, Iizuka Y: Complications associated 3. Caragine LP Jr, Halbach VV, Dowd CF, Higashida RT: Intra- with transvenous embolisation of cavernous dural arteriove- orbital arteriovenous fistulae of the ophthalmic veins treated nous fistula. Acta Neurochir (Wien) 141:1265–1271, 1999 by transvenous endovascular occlusion: technical case report. 24. Quiñones D, Duckwiler G, Gobin PY, Goldberg RA, Viñuela Neurosurgery 58 (1 Suppl):ONS-E170, 2006 F: Embolization of dural cavernous fistulas via superior oph- 4. Cognard C, Januel AC, Silva NA Jr, Tall P: Endovascular thalmic vein approach. AJNR Am J Neuroradiol 18:921– treatment of intracranial dural arteriovenous fistulas with cor- 928, 1997 tical venous drainage: new management using Onyx. AJNR 25. Reis CV, Gonzalez FL, Zabramski JM, Hassan A, Deshmukh Am J Neuroradiol 29:235–241, 2008 P, Albuquerque FC, et al: Anatomy of the superior ophthalmic 5. Dashti SR, Fiorella D, Spetzler RF, Albuquerque FC, Mc- vein approach for direct endovascular access to vascular le- Dougall CG: Transorbital endovascular embolization of dural sions of the orbit and cavernous sinus. Neurosurgery 64 (5 carotid-cavernous fistula: access to cavernous sinus through Suppl 2):318–323, 2009 direct puncture: case examples and technical report. Neuro- 26. Saatci I, Geyik S, Yavuz K, Cekirge HS: Endovascular treat- surgery 68 (1 Suppl Operative):75–83, 2011 ment of brain arteriovenous malformations with prolonged 6. Deguchi J, Yamada M, Ogawa R, Kuroiwa T: Transvenous intranidal Onyx injection technique: long-term results in 350 embolization for a purely intraorbital arteriovenous fistula. consecutive patients with completed endovascular treatment Case report. J Neurosurg 103:756–759, 2005 course. Clinical article. J Neurosurg 115:78–88, 2011 7. Derang J, Ying H, Long Y, Reifa S, Qiming W, Yimu F, et al: 27. Suzuki S, Lee DW, Jahan R, Duckwiler GR, Viñuela F: Trans- Treatment of carotid-cavernous sinus fistulas retrograde via the venous treatment of spontaneous dural carotid-cavernous superior ophthalmic vein (SOV). Surg Neurol 52:286–293, fistulas using a combination of detachable coils and Onyx. 1999 AJNR Am J Neuroradiol 27:1346–1349, 2006 8. Elhammady MS, Peterson EC, Aziz-Sultan MA: Onyx embo- 28. Tjoumakaris SI, Jabbour PM, Rosenwasser RH: Neuroendo- lization of a carotid cavernous fistula via direct transorbital vascular management of carotid cavernous fistulae. Neuro- puncture. Case report. J Neurosurg 114:129–132, 2011 surg Clin N Am 20:447–452, 2009 9. Elhammady MS, Wolfe SQ, Farhat H, Moftakhar R, Aziz- 29. White JB, Layton KF, Evans AJ, Tong FC, Jensen ME, Sultan MA: Onyx embolization of carotid-cavernous fistulas. Kallmes DF, et al: Transorbital puncture for the treatment Clinical article. J Neurosurg 112:589–594, 2010 of cavernous sinus dural arteriovenous fistulas. AJNR Am J 10. Gemmete JJ, Ansari SA, Gandhi DM: Endovascular techniques Neuroradiol 28:1415–1417, 2007 for treatment of carotid-cavernous fistula. J Neuroophthalmol 30. Wolfe SQ, Cumberbatch NM, Aziz-Sultan MA, Tummala R, 29:62–71, 2009 Morcos JJ: Operative approach via the superior ophthalmic 11. Goldberg RA, Goldey SH, Duckwiler G, Vinuela F: Manage- vein for the endovascular treatment of carotid cavernous fistu- ment of cavernous sinus-dural fistulas. Indications and tech- las that fail traditional endovascular access. Neurosurgery 66 niques for primary embolization via the superior ophthalmic (6 Suppl Operative):293–299, 2010 vein. Arch Ophthalmol 114:707–714, 1996 31. Yu SC, Cheng HK, Wong GK, Chan CM, Cheung JY, Poon 12. Hanneken AM, Miller NR, Debrun GM, Nauta HJ: Treatment WS: Transvenous embolization of dural carotid-cavernous of carotid-cavernous sinus fistulas using a detachable balloon fistulae with transfacial catheterization through the superior catheter through the superior ophthalmic vein. Arch Oph- ophthalmic vein. Neurosurgery 60:1032–1038, 2007 thalmol 107:87–92, 1989 32. Zaidat OO, Lazzaro MA, Niu T, Hong SH, Fitzsimmons BF, 13. Kirsch M, Henkes H, Liebig T, Weber W, Esser J, Golik S, et Lynch JR, et al: Multimodal endovascular therapy of traumat- al: Endovascular management of dural carotid-cavernous sinus ic and spontaneous carotid cavernous fistula using coils, n- fistulas in 141 patients. Neuroradiology 48:486–490, 2006 BCA, Onyx and stent graft. J Neurointerv Surg 3:255–262, 14. Komiyama M, Morikawa K, Fu Y, Yagura H, Yasui T, Baba M: 2011 Indirect carotid-cavernous sinus fistula: transvenous embolization from the external jugular vein using a superior ophthalmic vein approach. A case report. Surg Neurol 33:57–63, 1990 15. Lee JW, Kim DJ, Jung JY, Kim SH, Huh SK, Suh SH, et al: Embolisation of indirect carotid-cavernous sinus dural arte- Manuscript submitted January 2, 2012. rio-venous fistulae using the direct superior ophthalmic vein Accepted January 27, 2012. approach. Acta Neurochir (Wien) 150:557–561, 2008 Please include this information when citing this paper: DOI: 16. Leibovitch I, Modjtahedi S, Duckwiler GR, Goldberg RA: 10.3171/2012.1.FOCUS123. Lessons learned from difficult or unsuccessful cannulations Address correspondence to: Pascal M. Jabbour, M.D., Depart- of the superior ophthalmic vein in the treatment of cavernous ment of Neurological Surgery, Division of Neurovascular Surgery sinus dural fistulas. Ophthalmology 113:1220–1226, 2006 and Endovascular Neurosurgery, Thomas Jefferson University 17. Liu HM, Huang YC, Wang YH, Tu YK: Transarterial emboli- Hospital, 909 Walnut Street, 2nd Floor, Philadelphia, Pennsylvania sation of complex cavernous sinus dural arteriovenous fistulae 19107. email: [email protected].

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