Objective and importance: Carotid cavernous fistulas (CCF) type-D are often refractory to endovascular treatment. Surgery for these lesions is a well-described alternative option. A case of combined pretemporal approach to the cavernous sinus and direct coiling of CCF is presented as well as treatment options in cases of recurrent and intractable fistulas.
Clinical presentation: A 58-year-old woman with three years' history of double vision, headache, and numbness of the right upper extremity. On clinical examination she was noted to have congestion in the left eye with neurological examination without any deficits. Angiography revealed a type-D fistula..
Intervention: Patient underwent craniozygomatic pretemporal approach and direct coiling of the fistula. Intraoperative angiogram was done to confirm adequate obliteration of the fistula and preservation of flow in the parent artery..
Conclusion: Although the first-line treatment option for symptomatic cavernous sinus fistulas is endovascular embolization, surgery is indicated in cases where it fails to achieve satisfactory results. This is especially important when the patient has progressive neurological deficit, and in cases of compromised venous drainage. Direct coil-assisted obliteration of the fistula is a successful treatment option for these lesions..