case_images: PMC11799686_01
case_images: The left internal carotid artery (ICA) angiography revealed a high-flow shunt from the superior lateral wall of the left cavernous ICA directly into the left cavernous sinus. The shunted flow drained from the cavernous sinus into the bilateral superior ophthalmic veins and bilateral inferior petrosal sinuses, with reflux into the left superficial middle cerebral vein. (a) Posteroanterior view, (b) lateral view.
case_images: SNI-16-14-g001.jpg
case_images: PMC11799686_01_SNI-16-14-g001.jpg
case_images: F1
case_images: Cerebral angiography confirmed a high-flow shunt from the superior lateral wall of the left cavernous ICA directly into the left cavernous sinus, with a shunted pouch measuring 3.5 x 2.8 mm [Figure 1].
case_images: 3D rotational angiography of the left internal carotid artery confirmed the accurate guidance of the microcatheter (arrow) to the shunted pouch (arrowheads). (a) Axial view, (b) sagittal view, (c) Coronal view.
case_images: SNI-16-14-g002.jpg
case_images: PMC11799686_01_SNI-16-14-g002.jpg
case_images: F2
case_images: Aichi, Japan) insertion into the BENCHMARK to access the shunted pouch with 0.014 inch microguidewire ASAHI CHIKAI (ASAHI INTECC, Aichi, Japan) using left carotid angiography as a reference. At this point, 3D rotational angiography (3DRA) of the left ICA was performed to determine the working angle, and it confirmed accurate guidance of GREACH to the shunted pouch [Figure 2].
case_images: (a) The shunt obliterated after the 3rd coil insertion, although transvenous guided microcatheter (GREACH) remained in the shunted pouch, (b) GREACH was removed slightly out of the shunted pouch while leaving the microguidewire in the shunted pouch and the shunt was reignited (arrowheads), (c) GREACH was re-guided into the shunted pouch and the additional coil was inserted. GREACH was withdrawn spontaneously out of the shunted pouch and the shunt obliterated again.
case_images: SNI-16-14-g003.jpg
case_images: PMC11799686_01_SNI-16-14-g003.jpg
case_images: F3
case_images: SHOURYU, a Target360 ULTRA 4 mm x 6 cm (Stryker) was inserted from the GREACH with balloon assist and detached. Subsequently, a HydroSoft 3D 3 mm x 6 cm (Terumo, Tokyo, Japan) and a HydroSoft 3D 2.5 mm x 4 cm (Terumo) were inserted from the SL-10 with balloon assist and the shunted flow disappeared [Figure 3a]. As we were concerned, shunted flow reappeared [Figure 3b]. The shunted flow disappeared again, and the GREACH was withdrawn to the outside of the shunted pouch [Figure 3c]. The final left ICA angiography showed complete obliteration of the shunt [Figure 4].
case_images: Final left internal carotid angiography showed a complete obliteration of the shunt. (a) Posteroanterior view, (b) Lateral view.
case_images: SNI-16-14-g004.jpg
case_images: PMC11799686_01_SNI-16-14-g004.jpg
case_images: F4
case_images: The shunted flow disappeared again, and the GREACH was withdrawn to the outside of the shunted pouch [Figure 3c]. The final left ICA angiography showed complete obliteration of the shunt [Figure 4].