PMC10400908_01
3D TOF MRA axial source image (A) and MIP image (B) show a high signal in the right CS and dilated right SOV (white arrows). The source image shows that the high signal leading to the SOV was stronger in the medial part of the right CS. This suggests a shunted pouch located at the medial portion of the right CS. MRV oblique-axial thin MIP images (C and D) show that the SMCV joins the lateral part of the CS (white arrowheads) and the medial component of the CS continues to the SOV (white arrows). Both components of the CS are separated (C and D). CS: cavernous sinus; MIP: maximum intensity projection; MRV: MR venography; SMCV: superior middle cerebral vein; SOV: superior ophthalmic vein; TOF: time of flight
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Maximum intensity projection and axial source images of 3D time of flight MRA showed high signal structures in the medial part of the right CS contiguous with the dilated right SOV (Fig. 1A and 1B). SOV (Fig. 1C and 1D). Cerebral angiography showed the CSDAVF mainly supplied by multiple feeders from the right ascending pharyngeal artery (APA) and the meningohypophyseal trunk, which form a shunted pouch in the posteromedial portion to the right CS (Fig. 2A-2D). Shunted blood from the CSDAVF drained anteriorly and inferiorly along the medial surface of the cavernous portion of the internal carotid artery (ICA), and then anterolaterally to connect to the right SOV alone (Fig. 2A-2F).
Right internal carotid angiography (A and B) and right external carotid angiography (C and D) at the arterial phase showed a CSDAVF supplied by the right MHT (A and B), APA, MMA, artery of foramen rotundum, and artery of pterygoid canal (C and D). The shunt points were located in the right dorsal side of the CS and medial to the right ICA (black arrowheads in C and D). The CSDAVF drains to the right SOV alone (black arrows in A-D). The right common carotid angiography at the venous phase shows normal cerebral venous flow from the right SMCV through the right CS to the right IPS (black arrowheads in E-H). Drainage routes from the CSDAVF via the SOV (black arrows in E and F) and the small facial vein and superficial temporal vein are also noted. The right external carotid angiography at the venous phase shows reflux cerebral venous flow to the SOV (black arrows in I and J) and drains into small bilateral relatively small facial veins and superficial temporal veins (black arrowheads in I and J). APA: ascending pharyngeal artery; CSDAVF: cavernous sinus dural arteriovenous fistula; ICA: internal carotid artery; IPS: inferior petrosal sinus; MHT: meningohypophyseal trunk; MMA: middle meningeal artery; SMCV: superior middle cerebral vein; SOV: superior ophthalmic vein
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SOV (Fig. 1C and 1D). Cerebral angiography showed the CSDAVF mainly supplied by multiple feeders from the right ascending pharyngeal artery (APA) and the meningohypophyseal trunk, which form a shunted pouch in the posteromedial portion to the right CS (Fig. 2A-2D). Shunted blood from the CSDAVF drained anteriorly and inferiorly along the medial surface of the cavernous portion of the internal carotid artery (ICA), and then anterolaterally to connect to the right SOV alone (Fig. 2A-2F). The venous phase of right common carotid artery angiography showed normal cerebral venous drainage from the right SMCV through the right CS and the right IPS to the IJV, suggesting a septum existed between the drainage route of the CSDAVF and the normal cerebral venous drainage route within the CS (Fig. 2E-2H).
Axial (A-C), coronal (D-F), and sagittal (G-I) MPR images of 3DRA show the detailed anatomy of the feeders (black arrowheads surrounded by white), shunted pouch (white arrowheads), drainage vein (white arrows), and surrounding structures. 3DRA: 3D rotational angiography; MPR: multiplanar reconstruction
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Multiplanar reconstruction images of 3D rotational angiography (3DRA) of the right common carotid artery depicted the detailed anatomical relationships of the shunted pouch with surrounding structures (Fig. 3).
Schematic drawings of the anatomical and hemodynamic features of the presented case of CSDAVF and treatment strategy. A shunted pouch receiving blood from multiple feeders on the dorsal and medial sides of the CS, which runs anterior-inferiorly along the medial surface of the right ICA and turns anterolaterally at the inferior aspect of the ICA to join the SOV (A). The normal venous drainage from the SMCV runs posteriorly in the lateral part of the CS to join the IPS (B). Microcatheter entry path (black dotted arrow) and starting site of coil embolization (C). The area embolized with microcoils is from the shunted pouch and partially from the medial component of the CS. This eliminated the CSDAVF (D). APA: ascending pharyngeal artery; Cor.: coronal image; CS: cavernous sinus; CSDAVF: cavernous sinus dural arteriovenous fistula; ICA: internal carotid artery; IJV: internal jugular vein; IPS: inferior petrosal sinus; MC: microcatheter; MHT: meningohypophyseal trunk; Sag.: sagittal image; SMCV: superior middle cerebral vein; SOV: superior ophthalmic vein; SP: shunt point
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After evaluation of those images, we performed selective transvenous embolization (TVE) of the shunted pouch for the treatment of the CSDAVF (Fig. 4). Immediately after placement of 10 microcoils, the CSDAVF disappeared (Figs. 4C and 5C-5F).
A microcatheter was guided and placed via the ipsilateral IPS through the septum in the CS to the distal portion of the shunt pouch (black arrowheads) (A and B). Microcoils were placed in the shunted pouch and partially in the medial component of the CS (white arrows) from the shunt point (black arrowhead) (C and D). CCAG immediately after selective TVE shows complete occlusion of the CSDAVF (E and F). CCAG at the venous phase shows that normal venous drainage through the right CS tract is preserved (G and H). Black arrows in E-H indicate microcoils. CCAG: common carotid artery angiography; CS: cavernous sinus; CSDAVF: cavernous sinus dural arteriovenous fistula; IPS: inferior petrosal sinus; TVE: transvenous embolization
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A microcatheter (Eschelon-10; Medtronic, Minneapolis, MN, USA) was introduced through the 6F guiding sheath into the right CS via the right IPS using a 0.014 in. microguidewire (CHIKAI black; Asahi Intecc), and then it was introduced through the presumed septum into the shunted pouch deeply close to the shunt points (Fig. 5A and 5B). Immediately after placement of 10 microcoils, the CSDAVF disappeared (Figs. 4C and 5C-5F). Normal venous return from the right SMCV via the right CS was preserved (Fig. 5G and 5H).