Endovascular therapy for cavernous sinus vascular lesions

Vascular lesions in the cavernous sinus can cause serious neurological and ophthalmic complications owing to the anatomic relation of these lesions with important neurovascular structures, including cranial nerves, internal carotid artery, subarachnoid spaces, orbital contents, and deep and superficial cerebral venous channels. Well-recognized vascular lesions in the cavernous sinus include direct and indirect carotid-cavernous fistulae and cavernous carotid aneurysms. Over the past two decades, endovascular therapy has provided important therapeutic options for these challenging lesions. Indirect carotid-cavernous fistulae are one subgroup of dural arteriovenous malformations (DAVM). Their clinical significance is dependent on the venous drainage pattern. Ophthalmic complications may also be indications for aggressive therapy. Endovascular transarterial and, particularly, transvenous embolizations have been shown excellent results in managing indirect carotid-cavernous fistulae and low complications. Direct carotid-cavernous fistulae (CCF) are high-flow lesions, usually results of trauma or intracavernous aneurysm rupture. They typically present with progressive ophthalmic complaints and require treatment to prevent visual deterioration. Transarterial balloon and/or coil embolization of CCFs and transvenous coil embolization of the cavernous sinus are effective and safe management options with good results. Cavernous carotid aneurysms are relatively benign with low risk of subarachnoid hemorrhage. However, they may frequently reach giant size, causing mass effect on cavernous sinus contents. With systematic evaluation of the patient's cerebral circulation and its tolerance to carotid sacrifice, frequently, cavernous carotid aneurysms can be obliterated with permanent carotid occlusion without or with cerebral revascularization. New endovascular techniques, including balloon remodeling and stent assisted coil embolization, have made some constructive therapy possible for obliterating such aneurysms while preserving the parent carotid artery.