Superficial middle temporal vein as a pivotal route to embolize dural carotid-cavernous fistulas

Transfemoral transvenous embolization through the vein of Trolard and superficial middle cerebral vein for cavernous sinus dural arteriovenous fistula with isolated cortical vein drainage: A case report and literature review

Background:

Endovascular treatment may be challenging for cavernous sinus dural arteriovenous fistulas (CSDAVFs) with prominent leptomeningeal drainage without other accessible routes. We report a case of CSDAVF with isolated cortical venous successfully drainage treated by percutaneous transvenous embolization through the vein of Trolard and superficial middle cerebral vein (SMCV). We also review the literature of CSDAVFs treated by transvenous embolization through SMCV with or without combined surgical approach.

Case Description:

A 46-year-old woman presented with ocular symptoms and delayed treatment was encountered due to the COVID-19 pandemic. Cerebral angiography showed a CSDAVF (Barrow type D, Borden II, and Cognard II a + b) with isolated cortical vein drainage. Percutaneous transvenous access to the fistula through the inferior petrosal sinus was attempted but failed. Transvenous embolization through the vein of Trolard and SMCV was further attempted, and satisfactory occlusion of the fistula was achieved with detachable coils. This access route was chosen because of the occlusion of other access routes and can obliterate the need for more invasive approach, that is, combined surgical and endovascular approach. Cerebral angiography obtained 6 months following the procedure, confirmed complete angiographic obliteration of the fistula. The patient made an uneventful recovery.

Conclusion:

To avoid invasive combined surgical and endovascular approach, transvenous embolization through the vein of Trolard and SMCV may be another accessible option for treating CSDAVF with isolated cortical venous drainage.

Middle temporal vein access for transvenous embolization of Cavernous sinus dural arteriovenous fistula: A case report and review of literature

Transvenous endovascular treatment is the first choice for treating most cavernous sinus dural arteriovenous fistulas (CDAVFs). Among several available venous routes, the inferior petrosal sinus is the most commonly used. We report a case of CDAVF treated with endovascular treatment via the middle temporal vein (MTV). A 65-year-old man presented with unilateral chemosis and exophthalmos for approximately two months. Digital subtraction angiography showed a right CDAVF with predominant venous drainage toward the right superior ophthalmic vein. The superior ophthalmic vein primarily drained into the dilated MTV. Both sides of the inferior petrosal sinus were occluded; therefore, transvenous embolization was performed via the MTV route. The fistula was completely obliterated. The patient's symptoms improved and the postoperative course was uneventful. The transfemoral approach via the MTV to treat CDAVF provides a crucial alternative when other venous routes are difficult or impossible to navigate with a catheter.