Collateral venous drainage into the orbit and skull base was observed (Figure 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 (Figure B and C). He experienced immediate cessation of his pulsatile tinnitus with an early improvement of the right VI nerve palsy and near-complete recovery of his 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:
Endovascular Techniques for Treatment of Carotid-Cavernous Fistula. Gemmete J Ansari S, Gandhi D. Journal of Neuro-Ophthalmology. March 2009 – Volume 29 – Issue 1 – p 62-71.
A 59-year-old man who is otherwise healthy presented to his PCP with progressive right-sided pulsatile tinnitus for 4-6 weeks. His PCP and ENT evaluated him extensively and prescribed multiple courses of steroids and subsequent unremarkable MRI and MRA imaging. He 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.