Post on 24-Jul-2020
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INTERVENTIONAL NEURORADIOLOGY
24/7Contact&Appointment(310)267-8761or8762
Cavernous Sinus Dural Arterial Venous Fistula – Facial Transvenous Approach
DIVISIONOFINTERVENTIONALNEURORADIOLOGY
Presentsapatientcasetreatedbytheteammembersofthedivision
andphysiciansandstaffoftheUCLAComprehensiveStrokeCenter
GARYDUCKWILER,MDDirectorandProfessor
FERNANDOVINUELA,MD
ProfessorEmeritus
REZAJAHAN,MDProfessor
SATOSHITATESHIMA,MD,DMSc
AssociateProfessor
NESTORGONZALEZ,MDAssociateProfessor
VIKTORSZEDER,MD,PhD
AssistantProfessor
PATIENTPRESENTATION
Figure1A:Aprightcarotidshowingfillingfromrighttoleftcavernoussinus(arrow)andsuperiorophthalmicvein(SOV)onleft(largearrow).
• A54-year-oldfemalewithahistoryoforiginallyrighteyechemosisandproptosiswithdiplopiawhothendevelopedlefteyechemosisandproptosis.Shestillhasdiplopiaaswellassomemilddecreasedvisualacuity.OnexamthereisaleftnerveVIpalsy.Diagnosisofleftcavernoussinusduralarteriovenousfistulawasmadeonclinicalandimagingevaluation.
TREATMENTPLANNING
• Asthesymptomsweresignificantandworsening,treatmentwasindicated.Thisworseningisoftenprecipitatedbyclottingoftheoutletveins(thesuperiorophthalmicvein(SOV)inhercase).
• Theclottingdoesmakeithardertogettothesiteofthefistulainthecavernoussinus.Howeverwithasmallbutpatentoutlettothefacialvein,itwaselectedtoapproachfromthisdifficultroute.
Figure1B:lateralviewwitharrowshowingcavernoussinus(siteoffistula),andlargearrowshowingsuperiorophthalmicvein.
(over)
Figure2:catheterizationfromfemoralveintojugulartofacialveintoangularveinoffaceforaccesstoSOV.Arrowshowsmicrocathetertip.Smallarrowsoutlinemedialorbit.
INTERVENTIONAL NEURORADIOLOGY
24/7Contact&Appointment(310)267-8761or8762
ProceduresprovidedbyDINRforadultandpediatricpatients
AcuteIschemicStroke
AcuteThrombectomy/ThrombolysisExtra/IntracranialAngioplasty/Stenting
BrainHemorrhage,Aneurysm/AVM/fistulae
AneurysmcoilingStent/balloonassistedaneurysmcoilingFlowdiverterstentdeviceembolization
AVM/DuralfistulaeembolizationVenousSinusThrombectomy/Thrombolysis
Directtranscutaneousembolization
ChronicOcclusiveCerebrovascularDiseaseExtra/IntracranialAngioplasty/Stenting
VenousSinusAngioplasty/Stenting
Head/neck/orbittumors&vascularmalformations,epistaxis
EndovascularembolizationDirectpercutaneousembolization
DivisionofInterventionalNeuroradiologyDavidGeffenSchoolofMedicineatUCLARonaldReaganUCLAMedicalCenter757WestwoodPlaza,Suite2129LosAngeles,CA90095-7437http://radiology.ucla.edu/site.cfm?id=217
Figure3:usingmanualcompressiontodirectthemicrocathetertiptoSOV.
Figure4:WirebeingpassedtositeoffistulafromfemoralveintofacialveintoSOVtocavernoussinus.
Figure5A:finalapangiogramshowingfillingofcavernoussinusfistulawithembolicmaterial,curingthefistula.
PATIENTOUTCOME
• ThepatientrecoveredcompletelywithtotaleliminationofthechemosisandrecoveryoftheIVNerveandeliminationofdoublevision.Withacombinationofinternalandexternal(manualmanipulation)ofthemicrocatheter,wewereabletosuccessfullyguidethesystemtothetargetandtreatsuccessfully.
Figure5B:finallateralangiogramshowingfillingofcavernoussinusfistulawithembolicmaterial,curingthefistula.