First reported single-surgeon transpalpebral hybrid approach for indirect cavernous carotid fistula: illustrative case

J Neurosurg Case Lessons. 2022 Jun 20;3(25):CASE22115. doi: 10.3171/CASE22115.


Background: Failure to reach the cavernous sinus after multiple transvenous attempts, although rare, can be challenging for neurointerventionists. The authors sought to demonstrate technical considerations and nuances of the independent performance of a novel hybrid surgical and endovascular transpalpebral approach through the superior ophthalmic vein (SOV) for direct coil embolization of an indirect carotid cavernous fistula (CCF), and they review salient literature regarding the transpalpebral approach.

Observations: An illustrative case, including patient history and presentation, was reviewed. PubMed, MEDLINE, and Embase databases were searched for articles published between January 1, 2000, and September 30, 2021, that reported ≥1 patient with a CCF treated endovascularly via the SOV approach. Data extracted included sample size, treatment modality, surgical technique, performing surgeon specialty, and procedure outcome. The authors' case illustration demonstrates the technique for the hybrid transpalpebral approach. For the review, 273 unique articles were identified; 14 containing 74 treated patients fulfilled the inclusion criteria. Oculoplastic surgery was the most commonly involved specialty (5 of 14 studies), followed by ophthalmology (3 of 14). Coiling alone was the treatment of choice in 12 studies, with adjunctive use of Onyx (Medtronic) in 2.

Lessons: The authors' technical case description, video, illustrations, and review provide endovascular neurosurgeons with a systematic guide to conduct the procedure independently.

Keywords: CCA = common carotid artery; CCF = carotid cavernous fistula; ICA = internal carotid artery; IOP = intraocular pressure; IPS = inferior petrosal sinus; NBCA = N-butyl cyanoacrylate; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta Analyses; SOV = superior ophthalmic vein; SPS = superior petrosal sinus; coil; endovascular embolization; indirect carotid cavernous fistula; superior ophthalmic vein; transpalpebral.

Publication types

  • Case Reports