case_images: PMC11787942_01
case_images: Initial MRA shows high intensity from the left cavernous sinus to the dilated SOV (red arrow) (A-E), and ASL also shows high intensity (white arrow) (F). ASL, arterial spin labeling; SOV, superior ophthalmic vein
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case_images: PMC11787942_01_jnet-19-01-2024-0047-g001.jpg
case_images: F1
case_images: Right ICA angiography shows a faintly visible left cavernous sinus through the meningeal branch (A, black arrow). Left ICA angiography shows the flow from the meningeal branch and recurrent meningeal artery into the cavernous sinus (B, black arrow). Left ECA angiography and cone beam CT indicating the diffuse feeders, mainly the AMA (white arrow), MMA (yellow arrow), ascending pharyngeal artery (red arrow), and the AFR (blue arrow) that had converged to form a shunting point posterolateral to the cavernous sinus, with drainage into the SOV (C-F). Compared to the IPS, the facial vein to the angular vein appears relatively less tortuous (G, H). AFR, artery of foramen rotundum; AMA, accessory meningeal artery; ECA, external carotid artery; ICA, internal carotid artery; IPS, inferior petrosal sinus; MMA, middle meningeal artery; SOV, superior ophthalmic vein
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case_images: PMC11787942_01_jnet-19-01-2024-0047-g002.jpg
case_images: F2
case_images: Right internal carotid artery (ICA) angiography revealed a faintly visible left cavernous sinus through the meningeal branch (Fig. 2A), but no right external carotid artery (ECA) or left vertebral artery involvement was observed. Left ICA angiography showed flow from the meningeal branch and recurrent meningeal artery into the cavernous sinus. (Fig. 2B). Left ECA angiography and cone beam CT revealed that diffuse feeders, mainly the accessory meningeal artery, middle meningeal artery, ascending pharyngeal artery, and the artery of foramen rotundum (AFR), had converged to form a shunting pouch posterolateral to the cavernous sinus, with drainage into the SOV (Fig. 2C-2F). Compared to the inferior petrosal sinus (IPS), the facial vein to the angular vein was relatively less tortuous (Fig. 2G and 2H); therefore, we planned a transvenous embolization (TVE) via this approach route and performed the TVE under general anesthesia 1 week later.
case_images: PLSVC was an incidental finding when conforming left and right CCA angiography (red arrow). The shunt disappeared after jugular vein puncture (A) and coil embolization via an IPS approach (B, C). CCA, common carotid artery; IPS, inferior petrosal sinus; PLSVC, persistent left superior vena cava
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case_images: F3
case_images: Angiography of the common carotid artery, including a venous phase at the right atrial level to confirm the approach route, revealed the PLSVC (Fig. 3A). After the shunt pouch was tightly packed with a coil, blood flow decreased but continued slightly, so additional coil embolization was performed above and below the coil mass of the shunt pouch, and the shunt disappeared (Fig. 3B and 3C).
case_images: A subsequent contrast-enhanced CT scan confirmed the PLSVC (red arrow) opening into the right atrium through the coronary sinus, and a definitive diagnosis was performed (A-E). PLSVC, persistent left superior vena cava
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case_images: PMC11787942_01_jnet-19-01-2024-0047-g004.jpg
case_images: F4