King Edward Memorial Hospital - Departments: Radiology

A sixty-five year-old-lady presented with blurring of vision and redness in the left eye since two months. She was apparently alright two months back and had been on treatment for adult onset hypertension. There was no history of trauma or any infection. She had occasional headaches.

Clinical examination showed redness in the left eye; conjunctival congestion and chemosis were present. The external ocular movements full, no bruit or pulsations were present over the eyeballs.

A plain and contrast enhanced CT scan showed a large superior ophthalmic vein and enlarged cavernous sinus.

With a diagnosis of a carotico-cavernous fistula, a DSA was performed. This showed a Type D carotico-cavernous fistula. The fistula derived supply from the dural branches from both the internal (Fig 1) and external carotid arteries. There was sluggish flow in the superior ophthalmic vein. There was no posterior drainage into the petrosal sinuses.

Fig 1

Embolisation was planned using a venous approach. A 6F guiding catheter was placed in the left internal jugular vein through the right femoral vein. Through a 6F sheath in the the left femoral artery, a 5F headhunter catheter was placed in the left carotid artery.

A .038 glide wire was used and the inferior petrosal sinus in the left side was probed for. The glide wire could be navigated into the petrosal sinus and into the cavernous sinus. The guiding catheter was placed near the petrosal sinus.

A microcatheter over a microguide wire was navigated into the cavernous sinus and into the venous side of the fistula (Fig. 2). Here GDC coils were deployed and the cavernous sinus was packed till the fistula was obliterated (Fig 3).


Fig 2	Fig 3

Post embolisation control angiogram showed complete obliteration of the fistula (Fig 4).

Fig 4

Immediately the proptosis disappeared and in a week the eye was normal.

Conclusion: Since there was a type D Carotico cavernous fistula the treatment is to be done by venous approach. It would have been impossible to embolise the many tiny dural branches from the internal and external carotid arteries safely and completely. Though the drainage of the fistula was anterior due to the existing anatomical communications, it was easy to get into the fistula from the posterior petrosal sinus and treat it.