PMC4352642_01
It is shown the right proptosis and bipalpebral edema (a). It also can be observed the congestion of conjunctival vessels in a "caput medusae" and "corkscrew" fashion (b and c)
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F1
The neuro-ophthalmologic examination revealed right corneal hypoesthesia, hyperemia of conjunctival vessels in a Caput medusae fashion; tarsal vessels and RE eyelid margin congestion in a corkscrew-like vessels [Figure 1].
T2-weighted magnetic resonance imaging (MRI) shows the right eye propotosis (a), the ingurgitation of orbital veins and edema of the extraocular muscles (b, arrows). Note the dilatation and the absence of signal due to high-flow in the left cavernous sinus (c and d, arrowheads) and in the circular sinus toward the right cavernous sinus (c and d, hollow arrows)
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F2
The magnetic resonance imaging showed infraorbital congestion with increased volume of the superior ophthalmic vein [Figure 2]. We noticed that both the proximal portion of the cavernous sinus and the intercavernous sinus were enlarged and with increased flow signal [Figure 2].
Digital subtraction (a: Lateral view, b: Left oblique view, and c: Later view and more lateralized than b) and selective three-dimensional (d: AP view) angiography of the left internal carotid artery. It is seen the pass to the left cavernous sinus through meningeal branches of the meningohipofisarial and inferolateral trunks (b and d, thin arrows). The contrast material passes through intercavernous sinus (b and d, arrows) into the right cavernous sinus (a, b and d, arrowheads). Retrograde flow is observed from the inferiro petrosal sinus (a, b, c and d, thick arrow) and the ophthalmic vein (c, star)
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F3
Through selective catheterization of the ICA and the external carotid artery (ECA) was evidenced the presence of a dural fistula to the left cavernous sinus through dural branches of ICA cavernous segment [Figure 3] and the internal maxillary artery [Figure 4], with retrograde flow into contralateral cavernous sinus through intercavernous sinus, and thence to the superior ophthalmic vein, right pteriogoid plexus and inferior petrosal right sinus.
Digital subtraction (a: Lateral view, b: Lateral view later stage than a and c: AP view) and selective three-dimensional (d: Anterolateral view) angiography of the left external carotid artery. It is observed the passage of contrast material through direct branches of the maxillary artery and in turn the middle meningeal artery toward the left cavernous sinus (a, c, d, thin arrows). The contrast material passes to the contralateral cavernous sinus (a-d, arrowhead) through intercavernous sinus (c and d, arrows). Retrograde flow can be seen through the inferior petrosal sinus (a-d, thick arrow) and the ophthalmic vein (b, star)
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F4
Through selective catheterization of the ICA and the external carotid artery (ECA) was evidenced the presence of a dural fistula to the left cavernous sinus through dural branches of ICA cavernous segment [Figure 3] and the internal maxillary artery [Figure 4], with retrograde flow into contralateral cavernous sinus through intercavernous sinus, and thence to the superior ophthalmic vein, right pteriogoid plexus and inferior petrosal right sinus.
Fistula management by contrast injection through arterial approach, where there are visualized the tributary vessels (a, thick arrow) and venous embolization. The distal end of the guide catheter was fixed at the level of the internal jugular vein (a, b and c: Arrowhead), and through this was passed a microcatheter that coursed the inferior petrosal sinus, the right cavernous and intercavernous sinuses (a-d and f, thin arrows). The distal end of the microcatheter was placed in the left cavernous sinus (b, arrow) and was started the coils placing and releasing (c-f, Star). By the end of angiographic embolization, meningeal vessels were observed, with no communication with the cavernous sinus (e, thick arrow)
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F5
Therefore, to access this sinus we used the femoral vein, traveling through the internal jugular vein, inferior petrosal sinus and right cavernous sinus respectively, to access to the intercavernous sinus and posteriorly set the distal end of the microcatheter at the level of the left cavernous sinus [Figure 5]. Fremont, CA) were used. Final angiographic control showed complete occlusion of the fistula [Figure 5].
Photograph of AO 1 week after treatment. The proptosis, bipalpebral edema, and congestion of conjunctival vessels are no longer observed (a and b). Eye movements are conserved (c-e)
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F6
At 24 h after embolization, the patient was discharged with a considerable reduction in the erythema, conjunctival congestion and proptosis of RE [Figure 6 and 7]; and with IOP of 15.5 mm Hg, then was suspended ocular hypotensive administration.
Magnetic resonance imaging 15 days after endovascular treatment. At orbital level is no longer observed extraocular muscle edema or bulking ophthalmic veins (a). The tetralogy of fallot angio magnetic resonance imaging shows absence of the fistula (b). Can be appreciated hypointensity originated by coils within the left cavernous and intercoronary sinuses (c and d, arrows), besides the signal absence of blood flow within the internal carotid artery (c and d, arrows)
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F7
At 24 h after embolization, the patient was discharged with a considerable reduction in the erythema, conjunctival congestion and proptosis of RE [Figure 6 and 7]; and with IOP of 15.5 mm Hg, then was suspended ocular hypotensive administration.