J Cerebrovasc Endovasc Neurosurg.  2022 Mar;24(1):44-50. 10.7461/jcen.2021.E2021.06.008.

Middle temporal vein access for transvenous embolization of Cavernous sinus dural arteriovenous fistula: A case report and review of literature

• Kim SC
• Kim JH
• Kim CH
• Lee CY

• KMID: 2527594
• DOI: http://doi.org/10.7461/jcen.2021.E2021.06.008

Abstract

Transvenous endovascular treatment is the first choice for treating most cavernous sinus dural arteriovenous fistulas (CDAVFs). Among several available venous routes, the inferior petrosal sinus is the most commonly used. We report a case of CDAVF treated with endovascular treatment via the middle temporal vein (MTV). A 65-year-old man presented with unilateral chemosis and exophthalmos for approximately two months. Digital subtraction angiography showed a right CDAVF with predominant venous drainage toward the right superior ophthalmic vein. The superior ophthalmic vein primarily drained into the dilated MTV. Both sides of the inferior petrosal sinus were occluded; therefore, transvenous embolization was performed via the MTV route. The fistula was completely obliterated. The patient’s symptoms improved and the postoperative course was uneventful. The transfemoral approach via the MTV to treat CDAVF provides a crucial alternative when other venous routes are difficult or impossible to navigate with a catheter.

Keyword

Carotid-cavernous arteriovenous fistula; Cavernous sinus; Endovascular treatment; Middle temporal vein

Figure

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  Fig. 1. Axial magnetic resonance angiography source image showing (A) superior ophthalmic vein dilatation (white arrow) with (B) prominent vascularity at the cavernous sinus (thick white arrow).

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  Fig. 2. Right cavernous sinus dural arteriovenous fistula in a 65-year-old man. (A) Lateral-view angiogram from the right external carotid artery, obtained before embolization, shows predominant venous drainage toward the superior ophthalmic vein (white arrow). (B) Lateral-view angiogram from the right external carotid artery shows middle temporal vein dilatation (thin black arrow), superficial temporal vein (white arrow), retromandibular vein (thick black arrow). (C) Anteroposterior-view angiogram of the right external carotid artery. (D) Lateral-view angiogram from the right internal carotid artery shows multiple arterial feeders.

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  Fig. 3. Lateral-view angiogram of the right external carotid artery showing transvenous embolization via the MTV vein route. (A) A microcatheter advanced into the MTV (thick black arrow) and shows gentle progression to the nasofrontal vein (black arrow). (B) During detachable coil packing at the cavernous sinus. Fistula was completely obliterated with the detachable coil. (C) Angiogram with advanced microcatheter via MTV. MTV, middle temporal vein.

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  Fig. 4. Postoperative digital subtraction angiography (DSA) and magnetic resonance angiography. (A) The final DSA shows complete occlusion of the cavernous sinus dural arteriovenous fistula. (B) Axial magnetic resonance angiography source image shows coil (white arrow) in the right anterior cavernous sinus area.

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