MANAGEMENT OF CAVERNOUS SINUS-DURAL FISTULAS - INDICATIONS AND TECHNIQUES FOR PRIMARY EMBOLIZATION VIA THE SUPERIOR OPHTHALMIC VEIN

Objective: To describe indications and surgical techniques for emboliz ation of cavernous sinus-dural fistulas (CDF) by passing platinum coil s 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 cong estion underwent transvenous embolization. All patients had a dilated superior ophthalmic vein. All 10 patients had indications for treatmen t of fistulas on the basis of progressive glaucoma refractory to medic al management, venous stasis retinopathy with retinal ischemia, optic neuropathy, diplopia, exophthalmos with exposure keratopathy, cortical venous congestion with risk for intracranial hemorrhage, or a combina tion of these findings. Intervention: Nine of the 10 patients underwen t anterior orbitotomy via a lid-crease or sub-brow incision with cannu lation of the ipsilateral superior ophthalmic vein and embolization of the cavernous sinus with platinum coils, following an unsuccessful tr ansarterial 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 po stoperative intraocular pressure, and cosmetically acceptable cutaneou s 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 Row in the anterior superior ophthalmic vein on an giography suggesting thrombosis, yet the superior ophthalmic vein was easily accessed in the anterior orbit, and transvenous embolization wa s successfully performed. In 2 additional patients with nondilated sup erior ophthalmic veins, we were unable to gain surgical access and in 1 case severe bleeding occurred during attempted access of the small v ein. Conclusions: When performed by an experienced orbital surgeon and neuroradiology team, transvenous embolization of CDF via a dilated an terior superior ophthalmic vein is a technically straightforward, safe , and effective treatment for CDF and perhaps should be employed as pr imary therapy in cases with progressive orbital congestive symptoms. I f the superior ophthalmic vein is not dilated or if it is located deep in the orbit, transorbital venous access may not be possible.