PMC8720457_01
(a) Magnetic resonance angiography suggests cavernous sinus dural arteriovenous fistula (CSDAVF). (b) Time-of-flight angiography suggests CSDAVF (red arrowhead) and dilation of the superior orbital vein (red arrow). (c) Lateral view of right external cerebral angiography reveals the CSDAVF fed by branches of the external carotid artery, has multiple shunted pouches located in the cavernous sinus, and drains into superior orbital vein (SOV), inferior petrosal sinus (IPS), and superficial middle cerebral veins (SMCVs). (d) Anteroposterior (AP) view of right external cerebral angiography reveals the CSDAVF fed by branches of the external carotid artery, has multiple shunted pouches located in the cavernous sinus, and drains into bilateral SOVs, IPSes, and SMCVs. (e) AP view of left external cerebral angiography reveals the CSDAVF fed by branches of the external carotid artery, has multiple shunted pouches located in bilateral compartments of the cavernous sinus, and drains into bilateral SOVs, IPSes, and SMCVs. (f) Lateral view of left external cerebral angiography reveals the CSDAVF fed by branches of the external carotid artery, has multiple shunted pouches located in the cavernous sinus, and drains into SOV, IPS, and SMCVs.
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DSA revealed the CSDAVF fed by branches of the internal carotid artery and external carotid artery. DSA also revealed that the CSDAVF had multiple shunted pouches located in bilateral compartments of the CS and draining into bilateral SOVs, inferior petrosal sinuses (IPSs), and superficial middle cerebral veins (SMCVs) [Figure 1c-f].
(a) Anteroposterior (AP) view of right external cerebral angiography just after superselective shunt occlusion (SSSO) reveal the drainage route into the left superior orbital vein (SOV) has deteriorated, while that into the right SOV remains to a slight extent (red arrow). (b) AP view of right internal cerebral angiography just after SSSO reveal the drainage route into the left SOV has deteriorated, while that into the right SOV remains to a slight extent (red arrow). (c) AP view of left internal cerebral angiography reveal that the left feeders into the cavernous sinus dural arteriovenous fistula (CSDAVF) have been obliterated. (d) AP view of left external cerebral angiography reveal that the left feeders into the CSDAVF have been obliterated.
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IPS [Video 3]. SSSO was successfully performed [Figure 2a-d]. Immediately after SSSO, the drainage route into the left SOV was seen to be deteriorated, while that into the right SOV only slightly remained.
(a) Time-of-flight (TOF) angiography just after first operation shows dilatation of bilateral superior orbital veins (SOVs) has improved (red arrow) and the cavernous sinus dural arteriovenous fistula (CSDAVF) has been obliterated (red arrowhead). (b) Venous-arterial spin labeling (ASL) confirms increased signal intensity at bilateral SOVs. (c) TOF angiography on the 1 month later from superselective shunt occlusion (SSSO) shows dilatation of the SOVs (red arrow) and obliteration of the CSDAVF (red arrowhead). (d) Venous-ASL on the 1 month later from SSSO reveals resolution of increased signal intensity in the left SOV, but slight remnant hyperintensity of the right SOV. (e) TOF angiography on the 2 months later from SSSO shows dilatation of only the right SOV (red arrow) and confirmation of hyperintense signal in the right CS (red arrowhead). (f) Venous-ASL on the 2 months later from SSSO shows exacerbation of signal hyperintensity in the right SOV.
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On the other hand, TOF angiography showed dilatation of bilateral SOVs had improved and CSDAVF was obliterated [Figure 3a and b]. One month after SSSO, bilateral neuro-ophthalmic symptoms had worsened, especially on the right side. Venous-ASL showed increased signal intensity in bilateral SOVs had improved compared to the one immediately after SSSO, although signal intensity remained slightly in the right SOV [Figure 3c and d].
(a) Right external cerebral angiography demonstrate recurrence of cavernous sinus dural arteriovenous fistula (CSDAVF) draining into the right superior orbital vein (SOV) (red arrow). (b) Right internal cerebral angiography demonstrate recurrence of CSDAVF draining into the right SOV (red arrow). (c) Left internal cerebral angiography also demonstrate recurrence of CSDAVF draining into the right SOV (red arrow). (d) Left external cerebral angiography also demonstrate recurrence of CSDAVF draining into the right SOV (red arrow). (e) Postoperative right cerebral angiography reveals complete obliteration of the CSDAVF. (f) Postoperative left cerebral angiography reveals complete obliteration of the CSDAVF.
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DSA to judge whether true worsening had occurred. DSA revealed recurrence of CSDAVF with a drainage route only into the right SOV [Figure 4a-d]. Finally, CSDAVF was obliterated completely on both DSA and venous-ASL [Figure 4e and f].