Management of cavernous sinus-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein
R. A. Goldberg, S. H. Goldey, G. Duckwiler and F. Vinuela
Department of Orbital and Ophthalmic Plastic and Reconstructive Surgery, Jules Stein Eye Institute, Los Angeles, USA.
OBJECTIVE: To describe indications and surgical techniques for embolization
of cavernous sinus-dural fistulas (CDF) by passing platinum coils through a
cannulated superior ophthalmic vein based on our clinical experience.
DESIGN: Retrospective clinical review. SETTING: University tertiary
referral hospital and eye institute. PATIENTS: Over a 3-year period, 10
consecutive patients with CDF and progressive orbital congestion underwent
transvenous embolization. All patients had a dilated superior ophthalmic
vein. All 10 patients had indications for treatment of fistulas on the
basis of progressive glaucoma refractory to medical management, venous
stasis retinopathy with retinal ischemia, optic neuropathy, diplopia,
exophthalmos with exposure keratopathy, cortical venous congestion with
risk for intracranial hemorrhage, or a combination of these findings.
INTERVENTION: Nine of the 10 patients underwent anterior orbitotomy via a
lid-crease or sub-brow incision with cannulation of the ipsilateral
superior ophthalmic vein and embolization of the cavernous sinus with
platinum coils, following an unsuccessful transarterial embolization. One
patient underwent a primary transvenous embolization. MAIN OUTCOME
MEASURES: Successful closure of the fistula on angiography, return of
baseline visual acuity, normalization of postoperative intraocular
pressure, and cosmetically acceptable cutaneous scar. RESULTS: All 10
patients had prompt resolution of symptoms and halt of progressive visual
loss following occlusion of the fistulas. Two patients had no flow in the
anterior superior ophthalmic vein on angiography suggesting thrombosis, yet
the superior ophthalmic vein was easily accessed in the anterior orbit, and
transvenous embolization was successfully performed. In 2 additional
patients with nondilated superior ophthalmic veins, we were unable to gain
surgical access and in 1 case severe bleeding occurred during attempted
access of the small vein. CONCLUSIONS: When performed by an experienced
orbital surgeon and neuroradiology team, transvenous embolization of CDF
via a dilated anterior superior ophthalmic vein is a technically
straightforward, safe, and effective treatment for CDF and perhaps should
be employed as primary therapy in cases with progressive orbital congestive
symptoms. If the superior ophthalmic vein is not dilated or if it is
located deep in the orbit, transorbital venous access may not be possible.
