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Table of Contents    
CASE REPORT
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1649-1651

Cone Beam CT to Guide Transorbital Treatment of a Cavernous Sinus Dural Arteriovenous Fistula in a Patient with Middle Meningeal Artery Origin of the Ophthalmic Artery


1 Department of Neurointerventional Radiology, Royal Care Super Specialty Hospital, Neelambur, Coimbatore, Tamil Nadu, India
2 Department of Anaesthesiology, Royal Care Super Specialty Hospital, Neelambur, Coimbatore, Tamil Nadu, India
3 Department of Neurosurgery, Royal Care Super Specialty Hospital, Neelambur, Coimbatore, Tamil Nadu, India

Date of Submission22-Aug-2020
Date of Decision11-Jul-2020
Date of Acceptance11-Jul-2020
Date of Web Publication30-Aug-2022

Correspondence Address:
Madan Mohan Balaguruswamy
Department of Neurointerventional Radiology, Royal Care Super Specialty Hospital, Neelambur, Coimbatore - 641 062, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355098

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 » Abstract 


Transorbital puncture to embolize cavernous sinus (CS) dural arteriovenous fistulas (DAVF) is a useful strategy when conventional transvenous routes are inaccessible. We report a case of bilateral CS DAVF associated with bilateral middle meningeal artery (MMA) origin of ophthalmic arteries (OA) who had recently undergone transvenous coil embolization. She presented with persistent symptoms of conjunctival congestion and proptosis in the left eye. Angiogram revealed residual left CS DAVF with dilated SOV. Inferior petrosal sinus or facial vein access was not possible. Transorbital access of the SOV was planned. Cone-beam CT (CBCT) angiography was used to delineate the relationship between the variant OA and SOV and also to plan a safe trajectory. Using fluoroscopy guidance, the SOV was punctured and embolization was done using Onyx-18. CBCT is a valuable tool in planning and executing transorbital treatment of CS DAVF, especially in the setting of variant OA.


Keywords: Cavernous sinus, cone-beam CT, dural fistula, ophthalmic artery, transorbital
Key Message: Transorbital puncture is to treat cavernous sinus dural arteriovenous fistula is feasible in the presence of ophthalmic artery variations.Cone Beam CT angiography helps in understanding the course of the artery and in planning a safe transorbital trajectory.


How to cite this article:
Balaguruswamy MM, Palanisamy S, Mohanasundaram PK, Madeswaran K. Cone Beam CT to Guide Transorbital Treatment of a Cavernous Sinus Dural Arteriovenous Fistula in a Patient with Middle Meningeal Artery Origin of the Ophthalmic Artery. Neurol India 2022;70:1649-51

How to cite this URL:
Balaguruswamy MM, Palanisamy S, Mohanasundaram PK, Madeswaran K. Cone Beam CT to Guide Transorbital Treatment of a Cavernous Sinus Dural Arteriovenous Fistula in a Patient with Middle Meningeal Artery Origin of the Ophthalmic Artery. Neurol India [serial online] 2022 [cited 2022 Oct 7];70:1649-51. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1649/355098




Endovascular embolization using a transvenous approach has become the mainstay in the treatment of cavernous sinus (CS) dural arteriovenous fistulas (DAVF).[1] When conventional transvenous approaches through the inferior petrosal sinus (IPS) or the facial vein have failed or are deemed impossible, transorbital puncture is a good alternative access into the CS.[2] The challenge with this approach is the safe access of the target vessel (CS or ophthalmic vein) avoiding vital orbital contents, including the globe, ophthalmic artery (OA), and the optic nerve (ON).

Transorbital puncture techniques described by earlier authors work under the assumption that the OA passes through the optic canal and predictably accompanies the ON.[2],[3],[4],[5] However, variations in OA origin and course are known to occur. We report a case of a CS DAVF associated with a middle meningeal artery (MMA) origin of OA in whom conventional transvenous access was not possible. Cone-beam CT (CBCT) was used to delineate the OA course and plan safe transorbital access into the Superior ophthalmic vein (SOV) and CS.


 » Case Report Top


A woman in her fifties presented with gradually progressive symptoms (proptosis, conjunctival congestion) in both eyes of one year duration. Bilateral SOV dilatation was noted on MR. Cerebral angiograms revealed CS DAVF involving both CS with feeders from bilateral external carotid and internal carotid artery branches. SOV was dilated on both sides. Bilateral IPS were occluded; and the right facial vein was the only outflow channel for bilateral fistulas. MMA origin of OA was noted on both sides. The embolization procedure was done under general anesthesia using direct right facial vein puncture. Coiling of left CS, intercavernous sinus and right CS were done sequentially.

Four weeks later, the patient presented with a slight worsening of the left eye symptoms and resolution of the right eye symptoms. Angiogram revealed residual arteriovenous fistula (AVF) on the left side with filling of left CS and left SOV [Figure 1]. There was no transvenous access route into the CS. As the SOV was slender (4.5mm) and located deep in the orbital cavity, surgical cutdown was considered impossible. Direct transorbital access of the SOV was planned. The procedure was done under general anesthesia. A 5-Fr angiographic catheter was placed in the left external carotid artery for control angiograms. We performed CBCT angiography using the IGS 520 flat-panel single plane angiography system (GE Healthcare, Wauwatosa, Wisconsin, USA). Protocol for CBCT angiography was a single 200° spin acquired at 30 fps over 5s with contrast injection at 3ml/s and X-ray delay of 1.5s. Volume rendered and cross-sectional images were evaluated [Figure 2] and [Figure 3]. The course of the OA through the Superior orbital fissure (SOF) and the orbit and its relationship with the dilated SOV was noted. A point just lateral to the infra-orbital ridge was chosen as the entry point. Te preferred target was a coil loop prolapsing into the SOV. Using the trajectory planning tool, the line connecting the two points was assessed in the CBCT images. The safety of the needle trajectory was confirmed and an ipsilateral frontal oblique working angle obtained. A 20G spinal needle was advanced along the orbital floor from the chosen entry point under fluoroscopy guidance [Figure 4]. Once the needle reached the target, a Traxcess wire (Microvention, Tustin, California, USA) was advanced into the SOV and CS. Over the wire, a 5F micropuncture access set was advanced into the SOV and an Echelon-10 microcatheter (Medtronic, Dublin, Ireland) was navigated into the CS [Figure 5]. Onyx-18 (Medtronic, Dublin, Ireland) was injected to fill the residual spaces and eliminate the AVF [Figure 6]. Ophthalmic symptoms resolved over the next four weeks with no recurrence of symptoms after one year.
Figure 1: Posteroanterior (a) and lateral (b) angiograms of the left external carotid artery shows residual opacification of the left cavernous sinus and left superior ophthalmic vein

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Figure 2: Oblique lateral projection (a) and Sagittal maximum intensity projection (MIP) of the Cone-beam CT angiography images (b) of the left external carotid artery shows the target coil loop prolapsing into the dilated Superior ophthalmic vein. Curved arrows in (a) and (b) denotes the Ophthalmic artery. The planned needle trajectory (white line) and the target (green asterisk) are shown in (b)

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Figure 3: Volume rendered images (a) and Maximum intensity projection images (b) of the Cone-beam CT angiography shows the planned needle trajectory (black line) and the target (green asterisk). Also shown are the Ophthalmic artery in (a)(straight arrow) and the optic canal in (b) (curved arrow)

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Figure 4: Fluoroscopic images with the advancing needle in Frontal oblique projection (a) and lateral oblique projection (b). Also shown in (A) are the Target coil loop (straight arrow) and the optic canal (curved arrow)

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Figure 5: (a) Photograph of the patient showing the Micropuncture access set with the entry point at the lower eyelid. (b) Microcatheter angiograms showing the residual spaces in the cavernous sinus and filling of the Superior ophthalmic vein

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Figure 6: Left External carotid angiogram (a) and Left Internal carotid angiogram (b) taken after onyx embolization reveals complete occlusion of the residual AVF

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 » Discussion Top


The OA, in its most common form, arises from the supracavernous ICA just after the latter penetrates the dura. It has a short intracranial course before it accompanies the ON to pass through the optic canal. In the orbit, it courses inferolateral to the ON, then turns medially by crossing either superior or inferior to the nerve. Further forward course of OA is along the medial aspect of the nerve.[6]

Embryologically, OA arises from the fusion of the primitive ophthalmic artery (POA) which passes through the optic canal and the orbital branch of the stapedial artery (StA) which passes through the SOF. Usually, the stapedial artery contribution regresses. If the POA contribution regresses and the StA dominates, it results in an MMA origin of OA.[7]Hayreh reported this variation in six of 170 anatomical specimens.[6] This variant artery arises from the frontal branch of the MMA and enters the orbit through the lateral end of the SOF. Within the orbit, it courses lateral to the ON, then turns obliquely medially to course over the ON, where it apparently 'rejoins' the course of a conventional OA.[8]

The technique of transorbital puncture of CS or ophthalmic veins has been described earlier.[2],[3],[4],[5] One critical aspect of this technique is the use of an ipsilateral frontal oblique projection to visualize the SOF and optic canal simultaneously. The rationale is to keep the needle pathway away from the optic canal to avoid the ON (and the OA which usually accompanies it).

In our case, as the OA was entering the orbit through SOF, we had concerns for its safety. CBCT angiography helped to delineate the course of the OA and also plan safe transorbital access. The utility of CBCT in transorbital treatment of CS DAVF has been reported earlier where the authors used additional navigation software to assist in needle advancement.[5],[9],[10] In our case, only fluoroscopy was used during needle advancement as we had a clear target in the coil loop.


 » Conclusion Top


Transorbital access to treat CS DAVF is a valuable but technically challenging procedure. CBCT can aid in successfully executing the procedure. This case underscores the utility of CBCT angiography in the presence of Ophthalmic artery variation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Zanaty M, Chalouhi N, Tjoumakaris SI, Hasan D, Rosenwasser RH, Jabbour P. Endovascular treatment of carotid-cavernous fistulas. Neurosurg Clin N Am 2014;25:551-63.  Back to cited text no. 1
    
2.
Wenderoth J. Novel approaches to access and treatment of cavernous sinus dural arteriovenous fistula (CS-DAVF): Case series and review of the literature. J Neurointerv Surg 2017;9:290-6.  Back to cited text no. 2
    
3.
Teng MM, Lirng JF, Chang T, Chen SS, Guo WY, Cheng CC, et al. Embolization of carotid cavernous fistula by means of direct puncture through the superior orbital fissure. Radiology 1995;194:705-11.  Back to cited text no. 3
    
4.
White JB, Layton KF, Evans AJ, Tong FC, Jensen ME, Kallmes DF, et al. Transorbital puncture for the treatment of cavernous sinus dural arteriovenous fistulas. AJNR Am J Neuroradiol 2007;28:1415-7.  Back to cited text no. 4
    
5.
Dashti SR, Fiorella D, Spetzler RF, Albuquerque FC, McDougall CG. Transorbital endovascular embolization of dural carotid-cavernous fistula: Access to cavernous sinus through direct puncture: case examples and technical report. Neurosurgery 2011;68 (1 Suppl Operative):75-83.  Back to cited text no. 5
    
6.
Hayreh SS. Orbital vascular anatomy. Eye 2006;20:1130-44.  Back to cited text no. 6
    
7.
Liu Q, Rhoton Jr AL. Middle meningeal origin of the ophthalmic artery. Neurosurgery 2001;49:401-7.  Back to cited text no. 7
    
8.
Lasjaunias P, Berenstein A, terBrugge K. Surgical Neuroangiography. Vol. 1. Clinical Vascular Anatomy and Variations. Berlin: Springer-Verlag: 2001. p. 426-55.  Back to cited text no. 8
    
9.
Puffer RC, Lanzino G, Cloft HJ. Using XperGuide planning software to safely guide catheter access to the cavernous sinus via transorbital puncture: A case report. Neurosurgery 2014;10(Suppl 2):E370-3.  Back to cited text no. 9
    
10.
Fu ZY, Feng Y, Ma C, Chen JC, Krings T, Zhao WY. Endovascular treatment of cavernous sinus dural arteriovenous fistulas via direct transorbital puncture using cone-beam computed tomography image guidance: Report of 3 cases. World Neurosurg 2019;130:306-12.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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