Transvenous embolization via the facial vein for intraorbital dural arteriovenous fistula: illustrative case

Jumpei Ienaga Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Aichi, Japan; and

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Tetsuya Tsukada Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Aichi, Japan; and

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Toru Watanabe Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Aichi, Japan; and

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Yosuke Sakai Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Aichi, Japan; and

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Kenji Uda Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan

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Kazunori Shintai Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Aichi, Japan; and

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Yoshio Araki Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Aichi, Japan; and
Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan

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Tetsuya Nagatani Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Aichi, Japan; and

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Yukio Seki Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Aichi, Japan; and

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BACKGROUND

Intraorbital arteriovenous fistula (IOAVF) is a rare type of intracranial fistula that presents with ocular signs similar to those of cavernous sinus dural arteriovenous fistula. The treatment of IOAVF is based on the vascular architecture of each case due to its infrequent occurrence. The authors report the case of an IOAVF that was successfully treated with embolization via the facial vein, with good outcomes.

OBSERVATIONS

A 78-year-old woman presented with left eyelid swelling, pulsatile ocular protrusion, and left ocular conjunctival hyperemia. Ophthalmological evaluation revealed elevated intraocular pressure; time-of-flight magnetic resonance angiography revealed a dilated left superior ophthalmic vein. Digital subtraction angiography showed an arteriovenous shunt in the left superior orbital fissure, which was treated using transvenous coil embolization. The patient experienced immediate improvement in left ocular protrusion and conjunctival hyperemia. Ophthalmological evaluation 1 month after treatment showed normal intraocular pressure in the left eye. No neurological symptoms were observed, and there was no recurrence of the arteriovenous shunt 3 months postoperatively.

LESSONS

The authors report a rare case of IOAVF treated with embolization via the facial vein with a good outcome. A thorough understanding of the vascular architecture using three-dimensional images is useful for determining endovascular access and procedures.

ABBREVIATIONS

CS = cavernous sinus; CT = computed tomography; DAC = distal access catheter; dAVF = dural arteriovenous fistula; DSA = digital subtraction angiography; IOAVF = intraorbital arteriovenous fistula; IOP = intraocular pressure; MPR = multiplanar reconstruction; SOV = superior ophthalmic vein; TAE = transarterial embolization; TVE = transvenous embolization; 3D = three-dimensional

BACKGROUND

Intraorbital arteriovenous fistula (IOAVF) is a rare type of intracranial fistula that presents with ocular signs similar to those of cavernous sinus dural arteriovenous fistula. The treatment of IOAVF is based on the vascular architecture of each case due to its infrequent occurrence. The authors report the case of an IOAVF that was successfully treated with embolization via the facial vein, with good outcomes.

OBSERVATIONS

A 78-year-old woman presented with left eyelid swelling, pulsatile ocular protrusion, and left ocular conjunctival hyperemia. Ophthalmological evaluation revealed elevated intraocular pressure; time-of-flight magnetic resonance angiography revealed a dilated left superior ophthalmic vein. Digital subtraction angiography showed an arteriovenous shunt in the left superior orbital fissure, which was treated using transvenous coil embolization. The patient experienced immediate improvement in left ocular protrusion and conjunctival hyperemia. Ophthalmological evaluation 1 month after treatment showed normal intraocular pressure in the left eye. No neurological symptoms were observed, and there was no recurrence of the arteriovenous shunt 3 months postoperatively.

LESSONS

The authors report a rare case of IOAVF treated with embolization via the facial vein with a good outcome. A thorough understanding of the vascular architecture using three-dimensional images is useful for determining endovascular access and procedures.

ABBREVIATIONS

CS = cavernous sinus; CT = computed tomography; DAC = distal access catheter; dAVF = dural arteriovenous fistula; DSA = digital subtraction angiography; IOAVF = intraorbital arteriovenous fistula; IOP = intraocular pressure; MPR = multiplanar reconstruction; SOV = superior ophthalmic vein; TAE = transarterial embolization; TVE = transvenous embolization; 3D = three-dimensional

Dural arteriovenous fistulas (dAVFs) account for 10%–15% of intracranial vascular malformations. They can occur in any part of the dura mater; however, they are most common in the cavernous sinus (CS) and transverse-sigmoid sinus regions. Intraorbital arteriovenous fistulas (IOAVFs) are a rare type of intracranial fistula that often present with ocular signs similar to those of CS dAVFs.1 Spontaneous IOAVF is found mostly in the aged population (mean: 61 yrs old), with a male predominance.2 It is associated with a relatively high risk of visual deterioration (33%)2 on the affected side, and the choice of treatment depends on the angioarchitecture of the fistula in each case. Herein, we report the case of a dural IOAVF treated with embolization via the facial vein, which showed a good outcome.

Illustrative Case

A 78-year-old woman presented with a 1-month history of left eyelid swelling, pulsatile ocular protrusion, and conjunctival hyperemia (Fig. 1A). The patient had no history of trauma. Ophthalmological evaluation revealed elevated intraocular pressure (IOP; 15 mm Hg in the right eye and 27 mm Hg in the left eye), but there was no disturbance in visual acuity. Time-of-flight magnetic resonance angiography revealed a dilated left superior ophthalmic vein (SOV; Fig. 1B). A left internal carotid angiogram revealed a small dAVF at the posterior end of the opacified SOV (on the superior orbital fissure) supplied by a branch of the meningohypophyseal trunk. A left external carotid angiogram revealed another fistula point at the middle of the dilated SOV (within the orbit) supplied by the meningolacrimal artery branching from the middle meningeal artery. The venous phase of a left internal carotid angiogram showed that shunt flow in the SOV drained only into the facial vein and that normal cerebral venous blood flow to the inferior petrosal sinus through the CS was preserved (Fig. 2). Multiplanar reconstruction (MPR) images of the left internal carotid angiogram showed separation of the posterior end of the SOV from the superficial middle cerebral vein by some intervening tissue at the anterior part of the CS. A three-dimensional (3D) image of the external carotid angiography revealed two shunt points: (1) the anterior fistula point was fed by the meningolacrimal artery through the cranio-orbital foramen and the recurrent meningeal artery through the superior orbital fissure and (2) the posterior fistula point was fed by the accessory meningeal artery (Fig. 3). The 3D configuration image of contrast-enhanced computed tomography (CT) showed that the facial vein was not connected to the internal jugular vein but to the external and anterior jugular veins via the retromandibular vein (Fig. 4).

FIG. 1
FIG. 1

A: Clinical photograph showing chemosis of the patient’s left conjunctiva. B: Time-of-flight magnetic resonance angiography showing dilated left superior ophthalmic vein (SOV; arrows).

FIG. 2
FIG. 2

Anteroposterior (A) and lateral (B) views of the left internal carotid angiogram, arterial phase, showing the dilated SOV (arrows) without opacification of the cavernous sinus (CS), indicating the presence of an arteriovenous fistula isolated from the CS. Lateral view of the left internal carotid angiogram (C), venous phase, showing normal antegrade blood flow through the left CS. Magnified lateral views of left internal (D) and external (E) carotid angiograms, arterial phase, demonstrating small arteriovenous fistulas (arrows) fed by a branch from the meningohypophyseal trunk (D) and meningolacrimal artery (E). Multiplanar reconstruction image of the left internal carotid angiogram (F) showing separation of the posterior end of the SOV (asterisk) from the superficial middle cerebral vein (arrow) by some intervening tissue at the anterior part of the CS.

FIG. 3
FIG. 3

A three-dimensional (3D) image of a left external carotid angiography revealed two shunt points: the anterior SOV (single arrow) fistula point (single asterisk) was fed by the meningolacrimal artery (double arrows) through the cranio-orbital foramen and the recurrent meningeal (single arrowhead) artery through the superior orbital fissure, and the posterior fistula point (double asterisks) was fed by the accessory meningeal artery (double arrowheads).

FIG. 4
FIG. 4

A 3D configuration image of contrast-enhanced computed tomography (CT) showed that the facial vein (single white arrow) linking to the SOV (blue arrowhead) and the angular vein (blue arrow) was not connected to the internal jugular vein (double white arrows) but to the external jugular vein (single white arrowhead) and anterior jugular vein (double white arrowheads) via the retromandibular vein (white asterisk).

Considering the possibility of visual disturbances in the left eye due to elevated IOP, embolization of the arteriovenous shunt was indicated. Transvenous coil embolization of the involved SOV via the facial vein was planned. With the patient under general anesthesia, a 6-Fr Fubuki sheath (Asahi Intecc Co., Ltd.) was introduced into the left external jugular vein through the right femoral vein because CT findings indicated that the external jugular vein had lower flexibility than the anterior jugular vein. Afterward, a 130-cm 3.4-Fr Tactics (Technocrat Corp.) was placed into the facial vein as a distal access catheter (DAC). The left SOV was approached using a Headway Duo microcatheter (Terumo) and an Asahi Chikai guidewire (Asahi Intecc Co., Ltd.). The shunt points and SOV were embolized using 8 coils (Fig. 5A). Complete occlusion of the shunt was confirmed on digital subtraction angiography (DSA; Fig. 5B and C), and normal perfusion of the left eye was demonstrated by a retinal brush without any delay on left internal carotid angiogram. Venous return through the left CS was unaffected by the procedure (Fig. 5D).

FIG. 5
FIG. 5

Postoperative radiograph, lateral view (A), showing the extent of coil embolization. Lateral views of postoperative internal (B) and external (C) angiograms, arterial phase, demonstrating complete occlusion of the arteriovenous shunt. A postoperative venous phase internal carotid angiogram (D) demonstrating that the venous return through the left CS was unaffected by the procedure.

The patient’s left ocular protrusion and conjunctival hyperemia began to improve immediately after embolization, and ophthalmological evaluation 1 month later showed normalization of the left IOP. The patient had no neurological symptoms, and no recurrence of the arteriovenous shunt was observed 2 years postoperatively.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

Lv et al.2 reviewed case reports and literature reviews on the rarity of IOAVF and the evolution of its treatment. They reported 26 IOAVFs, 19 of which drained into the SOV or inferior ophthalmic vein.1–16 Furthermore, eight of the reported cases were specified as having no connection between the CS and draining vein.2,6,8,14,15,16 Thus, it can be deduced that IOAVF is a rare clinical condition. With regard to the anatomical isolation of this condition, Yamamoto et al.,17 in their case of IOAVF, considered that thrombus formation between the SOV and CS may have resulted in the intraorbital isolation of the drainage route. In the present case, MPR images from the left internal carotid angiogram showed some intervening tissue separating the SOV from the superficial middle cerebral vein at the anterior CS. Such an anatomical variation may have contributed to the isolation of shunted flow in the SOV from the CS in addition to the possibility of thrombus formation in the posterior end of the SOV.

Recently, transvenous embolization (TVE) has become the mainstay of IOAVF treatment.2 In the present case, the fistula was embolized using the transfemoral venous approach via the facial vein. Other possible methods for accessing the shunt point include reaching it from the inferior petrosal sinus via the CS and directly puncturing the SOV. Our case was characterized by the separation of the SOV from the shunt point and CS and percutaneous transorbital puncture of the SOV. In addition, our case was characterized by isolation of the drainer (SOV) from the CS, in which normal venous flow had been preserved. A potential risk of the trans-CS approach is that the access route through the thrombosed zone of the SOV may create a new draining route of the fistula to the CS, making additional embolization necessary. Direct catheterization of the surgically exposed SOV could skip over tortuous venous structures to the orbit; however, it is associated with the difficulty of exposing a small-caliber SOV. Percutaneous transorbital puncture of the SOV would be the last choice when other approaches are impossible because it is invasive and accompanied by potential complications, such as eyeball damage, intraorbital nerve injury, retrobulbar hematoma, internal carotid artery injury, and infection.18 Transarterial embolization (TAE) using liquid embolic agents is an effective treatment; however, it can cause visual impairment and external ophthalmoplegia in IOAVF.6 Therefore, TAE is considered an option when TVE is unsuccessful.19 In the present case, a less invasive transfemoral venous approach via the facial vein was selected, wherein a DAC improved the stability and handling of a microcatheter in the tortuous venous architecture. The combination of 3D DSA in the arterial phase in the external carotid artery and MPR image of the internal carotid angiography in the venous phase allowed for a detailed understanding of the vascular architecture. By understanding the detailed anatomical structures and accurately selecting the fistula point using a DAC, embolization was performed without using liquid embolic agents, which eliminated the risk of neurological complications.

Lessons

We reported a rare case of IOAVF treated with embolization via the facial vein, which showed a good outcome. A thorough understanding of the angioarchitecture of the fistula with MPR images helps in determining endovascular access and procedures.

Author Contributions

Conception and design: Tsukada, Ienaga. Acquisition of data: Tsukada, Ienaga, Sakai, Uda. Analysis and interpretation of data: Ienaga, Araki. Drafting of the article: Ienaga, Nagatani, Seki. Critically revising the article: Tsukada, Ienaga, Seki. Reviewed submitted version of the manuscript: Tsukada, Watanabe, Nagatani. Approved the final version of the manuscript on behalf of all authors: Tsukada. Study supervision: Tsukada, Shintai.

References

  • 1

    Williamson RW, Ducruet AF, Crowley RW, McDougall CG, Albuquerque FC. Transvenous coil embolization of an intraorbital arteriovenous fistula: case report and review of the literature. Neurosurgery. 2013;72(1):E130E134.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Lv X, Li W, Liu A, Lv M, Jiang C. Endovascular treatment evolution for pure intraorbital arteriovenous fistula: three case reports and literature review. Neuroradiol J. 2017;30(2):151159.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Rengachary SS, Kishore PR. Intraorbital ophthalmic aneurysms and arteriovenous fistulae. Surg Neurol. 1978;9(1):3541.

  • 4

    Freitas MA, Filho CA, Lima R, Marchiori E. Traumatic ophthalmic fistula simulating carotid-cavernous fistula. Neurosurgery. 1983;12(1):102104.

  • 5

    Ohtsuka K, Hashimoto M. Clinical findings in a patient with spontaneous arteriovenous fistulas of the orbit. Am J Ophthalmol. 1999;127(6):736737.

  • 6

    Kim AW, Kosmorsky GS. Arteriovenous communication in the orbit. J Neuroophthalmol. 2000;20(1):1719.

  • 7

    Subramanian PS, Gailloud PH, Heck DV, Tamargo RJ, Murphy KJ, Miller NR. Cook detachable coil embolization of a symptomatic, isolated orbital arteriovenous fistula via a superior ophthalmic vein approach. Neuroradiology. 2005;47(1):6265.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Hamada J, Morioka M, Kai Y, Sakurama T, Kuratsu J. Spontaneous arteriovenous fistula of the orbit: case report. Surg Neurol. 2006;65(1):5557.

  • 9

    Caragine LP Jr, Halbach VV, Dowd CF, Higashida RT. Intraorbital arteriovenous fistulae of the ophthalmic veins treated by transvenous endovascular occlusion: technical case report. Neurosurgery. 2006;58(1 Suppl):ONS-E170.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Yazici B, Yazici Z, Erdogan C, Rootman J. Intraorbital arteriovenous fistula secondary to penetrating injury. Ophthal Plast Reconstr Surg. 2007;23(4):275278.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Cheng KC, Chang CH, Lin WC. Spontaneous resolution of intraorbital arteriovenous fistulas. Ophthal Plast Reconstr Surg. 2009;25(3):245247.

  • 12

    Lin CJ, Blanc R, Clarençon F, et al. Transvenous embolization of an intraorbital arteriovenous fistula using Onyx. J Clin Neurosci. 2010;17(6):783785.

  • 13

    Sato K, Matsumoto Y, Kondo R, Tominaga T. Intraorbital arteriovenous malformation treated by transarterial embolization: technical case report. Neurosurgery. 2011;68(2 Suppl Operative):383-387.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Wigton EH, Wells JR, Harrigan MR, Long JA, Vicinanzo MG. Diagnosis and management of an intraorbital vascular fistula. Ophthal Plast Reconstr Surg. 2012;28(2):e39e41.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Naqvi J, Laitt R, Leatherbarrow B, Herwadkar A. A case of a spontaneous intraorbital arteriovenous fistula: clinico-radiological findings and treatment by transvenous embolisation via the superior ophthalmic vein. Orbit. 2013;32(2):124126.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Mishra SS, Panigrahi S, Satpathy PC, Das D. Intraorbital arteriovenous fistula with thrombosed varix: diagnosis and treatment without catheter angiography in a developing country. Surg Neurol Int. 2013;4:107.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Yamamoto Y, Yamamoto N, Satomi J, et al. Dural arteriovenous fistula in the superior orbital fissure: a case report. Surg Neurol Int. 2018;9:95.

  • 18

    Lv M, Jiang C, Liu D, Ning Z, Yang J, Wu Z. Direct percutaneous transorbital puncture under fluoroscopic guidance with a 3D skull reconstruction overlay for embolisation of intraorbital and cavernous sinus dural arteriovenous fistulas. Interv Neuroradiol. 2015;21(3):357361.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Sato H, Miyachi S, Hashimoto A, et al. Transarterial embolization of intraorbital dural arteriovenous fistula: a case report. Article in Japanese. No Shinkei Geka. 2019;47(7):777783.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1

    A: Clinical photograph showing chemosis of the patient’s left conjunctiva. B: Time-of-flight magnetic resonance angiography showing dilated left superior ophthalmic vein (SOV; arrows).

  • FIG. 2

    Anteroposterior (A) and lateral (B) views of the left internal carotid angiogram, arterial phase, showing the dilated SOV (arrows) without opacification of the cavernous sinus (CS), indicating the presence of an arteriovenous fistula isolated from the CS. Lateral view of the left internal carotid angiogram (C), venous phase, showing normal antegrade blood flow through the left CS. Magnified lateral views of left internal (D) and external (E) carotid angiograms, arterial phase, demonstrating small arteriovenous fistulas (arrows) fed by a branch from the meningohypophyseal trunk (D) and meningolacrimal artery (E). Multiplanar reconstruction image of the left internal carotid angiogram (F) showing separation of the posterior end of the SOV (asterisk) from the superficial middle cerebral vein (arrow) by some intervening tissue at the anterior part of the CS.

  • FIG. 3

    A three-dimensional (3D) image of a left external carotid angiography revealed two shunt points: the anterior SOV (single arrow) fistula point (single asterisk) was fed by the meningolacrimal artery (double arrows) through the cranio-orbital foramen and the recurrent meningeal (single arrowhead) artery through the superior orbital fissure, and the posterior fistula point (double asterisks) was fed by the accessory meningeal artery (double arrowheads).

  • FIG. 4

    A 3D configuration image of contrast-enhanced computed tomography (CT) showed that the facial vein (single white arrow) linking to the SOV (blue arrowhead) and the angular vein (blue arrow) was not connected to the internal jugular vein (double white arrows) but to the external jugular vein (single white arrowhead) and anterior jugular vein (double white arrowheads) via the retromandibular vein (white asterisk).

  • FIG. 5

    Postoperative radiograph, lateral view (A), showing the extent of coil embolization. Lateral views of postoperative internal (B) and external (C) angiograms, arterial phase, demonstrating complete occlusion of the arteriovenous shunt. A postoperative venous phase internal carotid angiogram (D) demonstrating that the venous return through the left CS was unaffected by the procedure.

  • 1

    Williamson RW, Ducruet AF, Crowley RW, McDougall CG, Albuquerque FC. Transvenous coil embolization of an intraorbital arteriovenous fistula: case report and review of the literature. Neurosurgery. 2013;72(1):E130E134.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Lv X, Li W, Liu A, Lv M, Jiang C. Endovascular treatment evolution for pure intraorbital arteriovenous fistula: three case reports and literature review. Neuroradiol J. 2017;30(2):151159.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Rengachary SS, Kishore PR. Intraorbital ophthalmic aneurysms and arteriovenous fistulae. Surg Neurol. 1978;9(1):3541.

  • 4

    Freitas MA, Filho CA, Lima R, Marchiori E. Traumatic ophthalmic fistula simulating carotid-cavernous fistula. Neurosurgery. 1983;12(1):102104.

  • 5

    Ohtsuka K, Hashimoto M. Clinical findings in a patient with spontaneous arteriovenous fistulas of the orbit. Am J Ophthalmol. 1999;127(6):736737.

  • 6

    Kim AW, Kosmorsky GS. Arteriovenous communication in the orbit. J Neuroophthalmol. 2000;20(1):1719.

  • 7

    Subramanian PS, Gailloud PH, Heck DV, Tamargo RJ, Murphy KJ, Miller NR. Cook detachable coil embolization of a symptomatic, isolated orbital arteriovenous fistula via a superior ophthalmic vein approach. Neuroradiology. 2005;47(1):6265.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Hamada J, Morioka M, Kai Y, Sakurama T, Kuratsu J. Spontaneous arteriovenous fistula of the orbit: case report. Surg Neurol. 2006;65(1):5557.

  • 9

    Caragine LP Jr, Halbach VV, Dowd CF, Higashida RT. Intraorbital arteriovenous fistulae of the ophthalmic veins treated by transvenous endovascular occlusion: technical case report. Neurosurgery. 2006;58(1 Suppl):ONS-E170.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Yazici B, Yazici Z, Erdogan C, Rootman J. Intraorbital arteriovenous fistula secondary to penetrating injury. Ophthal Plast Reconstr Surg. 2007;23(4):275278.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Cheng KC, Chang CH, Lin WC. Spontaneous resolution of intraorbital arteriovenous fistulas. Ophthal Plast Reconstr Surg. 2009;25(3):245247.

  • 12

    Lin CJ, Blanc R, Clarençon F, et al. Transvenous embolization of an intraorbital arteriovenous fistula using Onyx. J Clin Neurosci. 2010;17(6):783785.

  • 13

    Sato K, Matsumoto Y, Kondo R, Tominaga T. Intraorbital arteriovenous malformation treated by transarterial embolization: technical case report. Neurosurgery. 2011;68(2 Suppl Operative):383-387.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Wigton EH, Wells JR, Harrigan MR, Long JA, Vicinanzo MG. Diagnosis and management of an intraorbital vascular fistula. Ophthal Plast Reconstr Surg. 2012;28(2):e39e41.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Naqvi J, Laitt R, Leatherbarrow B, Herwadkar A. A case of a spontaneous intraorbital arteriovenous fistula: clinico-radiological findings and treatment by transvenous embolisation via the superior ophthalmic vein. Orbit. 2013;32(2):124126.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Mishra SS, Panigrahi S, Satpathy PC, Das D. Intraorbital arteriovenous fistula with thrombosed varix: diagnosis and treatment without catheter angiography in a developing country. Surg Neurol Int. 2013;4:107.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Yamamoto Y, Yamamoto N, Satomi J, et al. Dural arteriovenous fistula in the superior orbital fissure: a case report. Surg Neurol Int. 2018;9:95.

  • 18

    Lv M, Jiang C, Liu D, Ning Z, Yang J, Wu Z. Direct percutaneous transorbital puncture under fluoroscopic guidance with a 3D skull reconstruction overlay for embolisation of intraorbital and cavernous sinus dural arteriovenous fistulas. Interv Neuroradiol. 2015;21(3):357361.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Sato H, Miyachi S, Hashimoto A, et al. Transarterial embolization of intraorbital dural arteriovenous fistula: a case report. Article in Japanese. No Shinkei Geka. 2019;47(7):777783.

    • PubMed
    • Search Google Scholar
    • Export Citation

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