Transvenous embolization of carotid cavernous fistulas via the superior ophthalmic vein

Background: Treatment of choice for symptomatic carotid-cavernous and caver nous-dural fistulas is neuroradiologic intervention via the femoral artery. Owing to the location of the fistula and/or to anatomic variations, a dire ct surgical approach via the superior ophthalmic vein may be necessary for embolization. Methods: Three patients presented with exophthalmos, episcler al venous congestion, chemosis, restricted eye movement, and secondary glau coma. One patient had visual impairment and scotoma due to compression of t he optic nerve by the fistula. The tentative diagnosis of an arteriovenous fistula was confirmed in two cases by color Doppler imaging and in all thre e cases with cerebral arterial angiography (two carotid-cavernous fistulas, one cavernous-dural fistula). After an unsuccessful transarterial attempt, embolization via the superior ophthalmic vein was chosen. Results: In all three patients the preparation of the superior ophthalmic vein was performe d without any complications. In two cases the fistula could be embolized co mpletely with platinum coils. In one patient the placement of the microcath eter was impossible, because of an abnormal vascular pattern. Later on the fistula was successfully embolized by an approach via the femoral vein. All three patients had complete resolution of symptoms. There were no recurren ces. Conclusion: Embolization of carotid-cavernous and cavernous-dural fist ulas by a surgical approach via the superior ophthalmic vein represents saf e and effective treatment when standard transarterial access is impossible. The cooperation of an orbital surgeon and an invasive neuroradiologist can be of benefit for this rare group of patients.