Collateral venous drainage into the orbit and skull base was observed (Fig. A). After successful cannulation of the direct aperture between the right carotid artery and the cavernous sinus, balloon-assisted coil embolization of the posterolateral compartment was performed until the fistula was closed (Fig. B and C). She experienced immediate cessation of her pulsatile tinnitus with the early improvement of the right VI nerve palsy and near-complete recovery of her vision within 6 weeks.
Figure: (A) Right ICA Cavernous Fistula with Venous Shunting (B) Balloon Assisted Coil Embolization (C) Fistula Cured Post Embolization
Key Learning Points:
A 61-year-old woman who is otherwise healthy presented to her PCP with progressive right-sided pulsatile tinnitus for 4-6 weeks. Her PCP and ENT evaluated her extensively and prescribed multiple courses of steroids and subsequent unremarkable MRI and MRA imaging. She developed acute onset diplopia secondary to a new partial right VI nerve palsy several days prior to our evaluation. A cerebral angiogram confirmed the presence of a high flow direct fistula of the right internal carotid artery–right cavernous sinus.