case_images: PMC8942197_01
case_images: The left external carotid artery angiogram (a: Anteroposterior view, b: Lateral view), the right internal carotid artery angiogram (c: Anteroposterior view, d: Lateral view), and the right external carotid artery angiogram (e: Anteroposterior view, f: Lateral view) show a cavernous sinus dural arteriovenous fistula that is mainly fed by the left accessory meningeal artery, left artery of foramen rotundum (a and b), right meningohypophyseal trunk (c and d), and right ascending pharyngeal artery (e and f). The cavernous sinus dural arteriovenous fistula has a shunted pouch on the posteromedial compartment of the right cavernous sinus and drains into the right inferior petrosal sinus (arrows in a-f).
case_images: SNI-12-634-g001.jpg
case_images: PMC8942197_01_SNI-12-634-g001.jpg
case_images: F1
case_images: These feeding arteries converged at the posteromedial compartment of the right CS, formed a shunted pouch, and drained into the right IPS [Figure 1].
case_images: The left external carotid artery angiogram (a: Anteroposterior view, b: Lateral view) shows a slightly residual arteriovenous shunt of the right cavernous sinus.
case_images: SNI-12-634-g002.jpg
case_images: PMC8942197_01_SNI-12-634-g002.jpg
case_images: F2
case_images: Approximately 5 h after the start of treatment, a small amount of arteriovenous shunt remained [Figure 2], but she remained unable to rest.
case_images: The right internal carotid angiogram (a: Anteroposterior view, b: Lateral view) shows a cavernous sinus dural arteriovenous fistula that is fed by the right meningohypophyseal trunk and drains into the right superior ophthalmic vein (dotted arrows). The venous phase of the right internal carotid angiogram (c: Anteroposterior view, d: Lateral view) shows the cavernous sinus dural arteriovenous fistula draining from the superior ophthalmic vein to the superficial temporal vein (arrowheads), with ipsilateral inferior petrosal sinus occlusion. Axial (e) and sagittal (f) reformatted images of the rotational angiography show a shunted pouch located at the anterolateral compartment of the right cavernous sinus (arrows).
case_images: SNI-12-634-g003.jpg
case_images: PMC8942197_01_SNI-12-634-g003.jpg
case_images: F3
case_images: The right superior ophthalmic vein (SOV), the main drainer, drained into the STV [Figure 3].
case_images: The abruptly angulated and tortuous course from the superficial temporal vein (STV) to the superior ophthalmic vein (SOV) is shown in the Anteroposterior (a) and Lateral (b) views of the right internal carotid artery angiogram and in the Anteroposterior (c) and Lateral (d) views of snapshot images. A microcatheter (white arrows in a-d) cannot be navigated from the STV to the SOV, with a distal access catheter (white dotted arrows in a-d) guided into the STV. The right internal carotid artery angiogram (e: Anteroposterior view, f: Lateral view) shows the straightened STV route (white arrowheads in e and f) by inserting an ATHLETERUBY PT guidewire into the microcatheter. The distal access catheter can be guided from the STV to the angular vein (white dotted arrows in e-h) and a 5-F guiding catheter can guided from the distal retromandibular vein to the STV (black arrows in e-h). The microcatheter (white arrows in e-h) can be navigated into a shunted pouch of the right cavernous sinus and the microcatheter injection (g: Anteroposterior view, h: Lateral view) reveals the shunted pouch of the right cavernous sinus draining into the SOV. Transvenous coil embolization is performed and complete occlusion of cavernous sinus dural arteriovenous fistula is achieved on postprocedural angiography (i: Anteroposterior view, j: Lateral view).
case_images: SNI-12-634-g004.jpg
case_images: PMC8942197_01_SNI-12-634-g004.jpg
case_images: F4
case_images: ATHLETERUBY PT SUPPORT (Japan Lifeline Co., Tokyo, Japan), a CTO-dedicated guidewire, was inserted into the microcatheter, being careful not to allow the tip of the guidewire come out of the microcatheter, and the STV was linearized [Video 1]. After the TACTICS and the 5-F guiding catheter were guided farther distally, the microcatheter could be easily navigated into the right CS and complete occlusion of the CSDAVF was achieved by coil embolization [Figure 4].