J Neurosurg 119:247–251, 2013
©AANS, 2013

Treatment of a carotid cavernous fistula via direct transovale
cavernous sinus puncture
Technical note
Alberto Gil, M.D.,1 Luis López-Ibor, M.D.,1 Gerardo Lopez-Flores, M.D., Ph.D., 2
Hugo Cuellar, M.D., 3 Eduardo Murias, M.D., Ph.D., 4
and Gregorio Rodríguez-Boto, M.D., Ph.D. 5
Interventional Neuroradiology Unit and 5Neurosurgery Service, Hospital Clinico San Carlos; 2Neurosurgery
Service, Hospital San Francisco Asis, Madrid; 4Interventional Neuroradiology Unit, Hospital Universitario
Central de Asturias, Oviedo, Spain; and 3Interventional Neuroradiology Section, Departments of
Neurosurgery and Radiology, LSU Health Sciences Center, Shreveport, Louisiana
1

Endovascular treatment is the treatment of choice for indirect carotid cavernous fistulas (CCFs). Direct surgical
obliteration of CCFs is recommended in highly symptomatic patients or in those with an aggressive pattern of venous
drainage. However, this is a technically challenging approach associated with significant procedural morbidity. The
authors present a case in which they decided to attempt a novel access to the cavernous sinus through the foramen
ovale before recommending surgery for an otherwise untreatable dural CCF.
This 52-year-old man with an indirect CCF and neurological deficit had undergone several attempts to embolize the shunt by means of the standard approaches. Ultimately direct cavernous sinus access was obtained through
the foramen ovale, resulting in complete obliteration of the shunt. The occlusion was radiographically stable at the
6-month follow-up evaluation, and the patient has remained asymptomatic. Percutaneous transovale puncture of a
CCF is a feasible alternative to accessing the cavernous sinus when traditional transvenous catheterization or direct
superior ophthalmic vein approach is not possible.
(http://thejns.org/doi/abs/10.3171/2013.4.JNS121504)

Key Words
•
carotid cavernous fistula
•
direct puncture
foramen ovale •
cavernous sinus
•
vascular disorders

E

ndovascular treatment is the treatment of choice
for indirect carotid cavernous fistulas (CCFs). Usually, the pathological cavernous sinus is occluded
through the inferior petrosal sinus. In cases of failure of
the transvenous approach, alternatives include percutaneous puncture of accessible veins, such as the superior
ophthalmic vein. However, when these structures are not
patent, direct surgical exposure of the cavernous sinus is
required, especially in highly symptomatic patients or in
those with an aggressive pattern of venous drainage. In
one such patient, prior to undertaking an open surgical

Abbreviations used in this paper: AP = anteroposterior; CCF =
carotid cavernous fistula; ICA = internal carotid artery.

J Neurosurg / Volume 119 / July 2013

•

embolization

•

approach we attempted a novel access to the cavernous
sinus through the foramen ovale. The procedure was carried out using simultaneous biplanar fluoroscopic guidance, and occlusion of the fistula was achieved. We discuss this new percutaneous technique as an alternative to
direct surgery for the treatment of indirect CCF when the
endovascular or percutaneous approaches fail.

Illustrative Case

This 52-year-old man was referred to our institution
for a chronic symptomatic right dural CCF. The lesion was
treated unsuccessfully several times at another institution.
At admission, he was being treated with 600 mg per day
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of carbamazepine, due to left temporal lobe seizures associated with the abnormal cortical venous drainage of
the fistula. A cerebral angiogram revealed a dural right
CCF filling from the dural branches of the right external
and internal carotid arteries and draining to the contralateral basal vein of Rosenthal through the basilar plexus
(Fig. 1). Although the inferior petrosal sinus did not appear patent on the angiogram, our first attempt to occlude
the fistula was made through this route. The procedure
was unsuccessful, and radiosurgery was performed after
discharge. There was no radiological or symptomatic improvement at 2-year follow-up. A percutaneous puncture
of the foramen ovale was attempted due to failure of all
other nonsurgical methods (Fig. 2).

Technique

After induction of general anesthesia, the patient’s
head was secured to the angiography table. A 6-Fr guiding
catheter was inserted in the right ICA through a right femoral artery approach for angiographic guidance and to navigate a temporary occlusion balloon along the cavernous
segment of the ICA. A percutaneous puncture of the foramen ovale was performed according to the Mullan-Lich­tor
technique17 with a 14-gauge needle (Fig. 3). The needle was
slowly advanced through the right foramen ovale under
simultaneous biplanar fluoroscopic guidance. The lateral
fluoroscopic image was used to determine the depth of the
needle. After the stylet was retrieved, a 20-gauge spinal

Fig. 2. Artist’s illustration of the direct transovale cavernous sinus
puncture. Printed with permission of Marcos Gil.

needle, preshaped with a 15° curve in its distal portion, was
inserted through the trocar to perforate the external dural
layer of the cavernous sinus (Fig. 3). The direction of the tip
of the needle was controlled under simultaneous biplanar
fluoroscopy. When the pathological cavernous sinus was
reached, the stylet was removed from the spinal needle and
a 0.012-inch nitinol guidewire was advanced into the cavernous sinus (Fig. 4) with the objective of introducing a

Fig. 1. A: Right external carotid artery angiogram, AP view, showing
a right dural CCF filling from distal branches of the internal maxillary
artery and draining to the left basal vein of Rosenthal.   B: Right ICA
angiogram, lateral view, showing small dural branches supplying the
fistula.   C: Superselective left middle meningeal artery angiogram, AP
view, showing the contralateral venous drainage. Due to the small size
of the distal branches, a more distal position of the microcatheter could
not be achieved.   D: Superselective left meningohypophysial trunk
angiogram, lateral view, showing exclusive venous drainage of the fistula into the deep venous system. Embolization from this point was not
considered because of the potential risk of reflux of embolic agents into
the ICA and intracranial circulation.

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Fig. 3. Left: Detail of the 3D volume rendering reconstruction of
the access through the foramen ovale, during the procedure.   Right:
Right ICA roadmap image, AP view, showing the preshaped 20-gauge
spinal needle (arrow) inside the 14-gauge trocar.

J Neurosurg / Volume 119 / July 2013

Direct transovale cavernous sinus puncture

Fig. 4. Right ICA roadmap image showing the 0.012-inch guidewire
inside the fistula (arrow).

microcatheter. During these maneuvers, a right ICA angiogram was performed to confirm the position of the guidewire. The angiogram revealed a complete occlusion of the
fistula (Fig. 5). With evidence of occlusion of the CCF, we
terminated the procedure and removed the spinal needle
and trocar carefully. An intraoperative CT scan was performed to rule out complications. The postoperative course
was uneventful. The patient was transferred to the intensive
care unit for 24 hours and then to the ward to be discharged
a week after the procedure. A 6-month follow-up cerebral
angiogram showed persistent occlusion of the fistula.

Discussion

Endovascular treatment of indirect CCFs is usually
efficient and safe. The venous access to the cavernous sinus, first described by Debrun et al.5 is the treatment of
choice. Indirect CCFs are frequently associated with numerous small-caliber meningeal branches, making the arterial approach much less effective. In a majority of cases,
the fistula can be treated by occluding the pathological
cavernous sinus through a transvenous embolization via
the inferior petrosal sinus. This can be done even in cases
of local thrombosis.8,9 However, in some occasions, the
inferior petrosal sinus cannot be catheterized; alternative
J Neurosurg / Volume 119 / July 2013

Fig. 5. Right common carotid artery angiogram showing occlusion
of the fistula.

venous routes have been described, including the contralateral inferior petrosal sinus, the superior petrosal sinus,
and the transverse or facial veins.16
If these venous approaches fail, other minimally invasive alternatives may be used. Direct puncture of the
facial, angular, and superior ophthalmic veins can be performed. These approaches are particularly useful if the
veins are angiographically patent and wide enough, but
they are not viable options when the veins are too tortuous,14 stenotic, or thrombosed.11,15,19 In our patient, the inferior petrosal sinus was thrombosed, and the alternative
veins were not visualized angiographically. Surgical exposure of the superior ophthalmic vein to perform direct
puncture has also been described and can be particularly
useful if the facial and angular vein are not visualized or
prove to be too tortuous, but again the presence of a wide
superior ophthalmic vein is needed.7,20 When these techniques fail, a transorbital puncture of the cavernous sinus
can obviate the need for a craniotomy. Although its use
in the treatment of CCF has been described,1 this technique can be complicated by severe intraorbital hemorrhage.6,24 Other potential risks of this procedure include
nerve damage, globe puncture, infection, and laceration
of the ICA resulting in direct CCF.7
When the endovascular or percutaneous options fail,
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and especially in those patients with rapid deterioration
of ocular symptoms or in patients with an increased risk
of bleeding related to venous reflux into cortical or deep
veins,3 as in our patient, a direct surgical approach may be
the only option. However, this is a technically challenging
approach and is associated with significant procedural
morbidity.4,10
The foramen ovale is a well-described route of percutaneous access to perform minimally invasive procedures
in the trigeminal cistern2,23 for the treatment of trigeminal neuralgia.2,12,18,22 It has also been used to access the
middle cranial fossa to place electrodes in patients with
temporal lobe epilepsy.13,22 Exploiting its close anatomical
relationship with the lateral wall of the cavernous segment of the ICA, biopsy of cavernous sinus tumors via the
foramen ovale has also been reported.21,25
However, to access the cavernous sinus through the
foramen ovale, it is necessary to modify the MullanLichtor technique. First, a longer 20-gauge spinal needle
is used inside the trocar to reach the cavernous sinus.
Since the direction along the foramen ovale does not allow direct access to the cavernous sinus, a change in the
direction of the distal aspect of the spinal needle is necessary. Preshaping the distal aspect of the spinal needle
with a 15° curve allows one to enter the ipsilateral cavernous sinus, which lies medial to the foramen ovale. Finally, an endovascular occlusion balloon is positioned in
the cavernous ICA, as ICA injury has been reported as
a complication of foramen ovale puncture. In our case,
spontaneous occlusion of the shunt was probably due to
cavernous sinus thrombosis. Although no hematoma was
seen on posttreatment CT of the head, compression due
to a small intradural hematoma could also be responsible
for the occluded shunt. The occlusion was stable radiographically at the 6-month follow-up examination despite
the fact that no embolic material was used. Clinically, the
patient remains asymptomatic. We will continue to follow the patient with periodic clinical examinations and
imaging studies.

Conclusions

Percutaneous transfacial puncture of a CCF via the
foramen ovale is a feasible alternative to accessing the
cavernous sinus when traditional transvenous catheterization or a direct superior ophthalmic vein approach is
not possible. Spontaneous obliteration of a CCF by sinus
thrombosis may result from cavernous sinus catheterization. Further studies are needed to understand the complex arterial and venous relationships that exist at the internal aspect of the foramen ovale in patients with CCFs.
An elucidation of these relationships may allow safe and
easy implementation of a percutaneous transovale approach to the cavernous sinus.
Disclosure
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript preparation

250

in­clude the following. Conception and design: Gil, López-Ibor,
Mu­rias, Lopez-Flores. Acquisition of data: Gil, López-Ibor, Murias.
Anal­ysis and interpretation of data: Gil, Rodríguez-Boto. Drafting
the article: Gil, Cuellar. Critically revising the article: all authors.
Re­viewed submitted version of manuscript: all authors. Approved
the final version of the manuscript on behalf of all authors: Gil.
Ad­min­istrative/technical/material support: Gil. Study supervision:
Gil.
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Manuscript submitted August 8, 2012.
Accepted April 11, 2013.
Please include this information when citing this paper: published online May 10, 2013; DOI: 10.3171/2013.4.JNS121504.
Address correspondence to: Alberto Gil, M.D., Interventional
Neu­ro­ra­diology, Hospital Clinico San Carlos, Calle de Profesor
Martín Lagos, S/N, Madrid 28040, Spain. email: agil_garcia@yahoo.
com.

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