Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: Report of four cases and review of the literature

BACKGROUND The aim of this study is to describe the technique and results o f the endovascular approach through the thrombosed inferior petrosal sinus (IPS) for occlusion of dural cavernous sinus fistulas (DCSFs). METHODS In four patients presenting with clinically symptomatic DCSFs, the angiogram did not show opacification of the IFS, indicating that it neither drained the arteriovenous fistula nor the cerebral venous outflow. A large volume biplane phlebogram of the jugular bulb was obtained to identify a t hrombosed remnant of the IFS. We were able to navigate small hydrophilic ca theters and microguide wires through the thrombosed IFS into the ipsi- or c ontralateral CS. After reaching the fistula site the CS was packed with det achable platinum coils. RESULTS We were able to reach the fistula site and to achieve a dense packi ng of coils within the arteriovenous shunting zone in all of the patients. The final angiogram showed subtotal or complete occlusion of the arterioven ous fistula. All four patients recovered completely and showed disappearanc e of the fistula on follow-up arteriograms. One patient developed a transie nt sixth nerve palsy. No complications related to the approach were observe d. CONCLUSIONS For endovascular treatment, transvenous occlusion of DCSFs via the IFS is a feasible approach, even when this sinus is partially or comple tely thrombosed. Gentle handling of recently available, improved hydrophili c microguide wires and microcatheters allows effective and safe catheter na vigation into the CS. A phlebogram of the jugular bulb is very useful for i dentification of a thrombosed IFS. (C) 2000 by Elsevier Science Inc.