A new transvenous approach to the carotid-cavernous sinus via the inferior petrooccipital vein

Clinical article

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Object

The transvenous approach via the inferior petrosal sinus (IPS) is commonly used as the most appropriate for carotid-cavernous fistula (CCF) or cavernous sinus sampling. However, sometimes the IPS is not accessible because of anatomical problems and/or complications, therefore an alternative route is needed. In this paper, the authors present and discuss the utility of a transvenous approach to the cavernous sinus via the inferior petrooccipital vein.

Methods

Four patients, 3 with dural CCFs and the other with Cushing disease, in whom endovascular surgical attempts failed using a conventional venous approach via the IPS, underwent a transvenous approach to the cavernous sinus via the inferior petrooccipital vein (IPOV). One dural CCF case had only cortical venous drainage, the second CCF also mainly drained into the cortical vein with slight inflow into the superior ophthalmic vein and inferior ophthalmic vein, and the third demonstrated drainage into the superior and inferior ophthalmic veins and IPOV.

Results

In all cases, the cavernous sinus could be accessed successfully via this route and without complications.

Conclusions

The transvenous approach to the cavernous sinus via the IPOV should be considered as an alternative in cases when use of the IPS is precluded by an anatomical problem and there are no other suitable venous approach routes.

Abbreviations used in this paper: CCF = carotid-cavernous fistula; DMCV = deep middle cerebral vein; ECA = external carotid artery; IJV = internal jugular vein; IOV = inferior ophthalmic vein; IPOV = inferior petrooccipital vein; IPS = inferior petrosal sinus; SMCV = superficial middle cerebral vein; SOV = superior ophthalmic vein.

Article Information

Address correspondence to: Akira Kurata, M.D., Department of Neurosurgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minamik Sagamihara, Kanagawa 228-8555, Japan. email: akirak@med.kitasato-u.ac.jp.

Please include this information when citing this paper: published online June 17, 2011; DOI: 10.3171/2011.4.JNS102155.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 1. Left carotid angiogram, lateral view (A), showing a CCF with drainage into the SMCV (double arrows), the DMCV (single arrow), SOV, and IOV. The peripheral roots of the SOV and IOV lack any dilation. Digital subtraction angiography, anteroposterior view (B), and skull radiograph, anteroposterior view (C), showing venography from the microcatheter into the left cavernous sinus via the IPOV (4 arrows). SMCV = double arrows, DMCV = single arrow. Left carotid angiogram, anteroposterior (D) and lateral (E) views, after endovascular surgery showing complete obliteration of the fistula and no cortical venous reflux.

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    Case 2. Left carotid angiogram, anteroposterior (A) and lateral (B) views, showing a CCF with drainage limited to the SMCV (double arrows) and DMCV (single arrow). Skull radiograph, anteroposterior view (C), showing venography from the microcatheter into the left cavernous sinus via the IPOV (arrows). Left ECA angiogram, anteroposterior view (D), after endovascular surgery showing complete obliteration of the fistula and no cortical venous refluxes.

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    Case 3. Left carotid angiogram, anteroposterior (A) and lateral (B) views, showing a CCF with drainage into the SOV, IOV, and IPOV (4 arrows). Skull radiograph, anteroposterior (C) and lateral (D) views, showing the microcatheter with microguidewire introduced into the left cavernous sinus via the IPOV (4 arrows). Left carotid angiogram, anteroposterior view (E), after endovascular surgery showing complete obliteration of the fistula and no cortical venous reflux.

  • View in gallery

    Case 4. Venography, anteroposterior view (A), from a microcather in the right cavernous sinus. IPS = single arrow (left and right), IPOV = 4 arrows, tip of the microcatheters = asterisk, obstruction of the right IPS = double asterisks. Skull radiograph, anteroposterior (B) and lateral (C) views, showing a microcatheter introduced into the left cavernous sinus via the left IPS (single arrow) and a microcatheter introduced into the right cavernous sinus via the IPOV (4 arrows).

  • View in gallery

    Photograph showing the IPOV running in the extracranial groove of the petrooccipital fissure.

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    Schematic drawing of the IPOV by T. Katsuta. v. = vein

References

  • 1

    Agid RWillinsky RAHaw CSouza MPSVanek IJter-Brugge KG: Targeted compartmental embolization of cavernous sinus dural arteriovenous fistulae using transfemoral medial and lateral facial vein approaches. Neuroradiology 46:1561602004

  • 2

    Benndorf GBender ALehmann RLanksch W: Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature. Surg Neurol 54:42542000

  • 3

    Bošković MSavić VJosifov J: Über die Sinus Petrosi und ihre Zuflüsse. Gengenbaurs Morphol Jahrb 104:4204291963

  • 4

    Cheng KMChan CMCheug YL: Transvenous embolisation of dural carotid-cavernous fistulas by multiple venous routes: a series of 27 cases. Acta Neurochir (Wien) 145:17292003

  • 5

    Halbach VVHigashida RTHieshima GBHardin CWYang PJ: Transvenous embolization of direct carotid cavernous fistulas. AJNR Am J Neuroradiol 9:7417471988

  • 6

    Jahan RGobin YPGlenn BDuckwiler GRViñuela F: Transvenous embolization of a dural arteriovenous fistula of the cavernous sinus through the contralateral pteriogoid plexus. Neuroradiology 40:1891931998

  • 7

    Katsuta TMatsushima TUda K: [Surgical anatomy of the skullbase venous system: petroclival region.]. No Shinkei Geka 17:7387442008. (Jpn)

  • 8

    Lee JWKim DJJung JYKim SHHuh SKSuh SH: Embolisation of indirect carotid-cavernous sinus dural arterio-venous fistulae using the direct superior ophthalmic vein approach. Acta Neurochir (Wien) 150:5575612008

  • 9

    Miller DLDoppman JL: Petrosal sinus sampling: technique and rationale. Radiology 178:37471991

  • 10

    Miller NRMonsein LHDebrun GMTamargo RJNauta HJW: Treatment of carotid-cavernous sinus fistulas using a superior ophthalmic vein approach. J Neurosurg 83:8388421995

  • 11

    Mitsuhashi YNishio AKawahara SIchinose TYamauchi SNaruse H: Morphologic evaluation of the caudal end of the inferior petrosal sinus using 3D rotational venography. AJNR Am J Neuroradiol 28:117911842007

  • 12

    Mounayer CPiotin MSpelle LMoret J: Superior petrosal sinus catheterization for transvenous embolization of a dural carotid cavernous sinus fistula. AJNR Am J Neuroradiol 23:115311552002

  • 13

    Oishi HArai HSato KIizuka Y: Complications associated with transvenous embolisation of cavernous dural arteriovenous fistula. Acta Neurochir (Wien) 141:126512711999

  • 14

    San Millán Ruíz DGailloud PRüfenacht DADelavelle JHenry FFasel JH: The craniocervical venous system in relation to cerebral venous drainage. AJNR Am J Neuroradiol 23:150015082002

  • 15

    Shiu PCHanafee WNWilson GHRand RW: Cavernous sinus venography. Am J Roentgenol Radium Ther Nucl Med 104:57621968

  • 16

    Teramoto AYoshida YSanno NNemoto S: Cavernous sinus sampling in patients with adrenocorticotrophic hormonedependent Cushing's syndrome with emphasis on inter- and intracavernous adrenocorticotrophic hormone gradients. J Neurosurg 89:7627681998

  • 17

    Trolard P: Anatomie du système veineux de l'encéphale et du crane ParisThèse de la Faculté de Médecine de Paris1868. 132

  • 18

    Yamashita KTaki WNishi SSadato ANakahara IKikuchi H: Transvenous embolization of dural caroticocavernous fistulae: technical considerations. Neuroradiology 35:4754791993

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