Transorbital Puncture of the Cavernous Sinus to Treat a Dural Carotid-Cavernous Sinus Fistula

A 35-year old woman presented with left ocular injection, proptosis, and reduced vision. Cerebral angiography demonstrated a dural carotid-cavernous fistula supplied by internal and external carotid branches. Following endovascular embolization, the external carotid supply was obliterated. A residual fistula supplied by a branch of the ophthalmic artery and draining by the ophthalmic veins resulted in progressive glaucoma. Compartmentalization of the cavernous sinus precluded access to the fistula via the cerebral venous sinuses. Attempted transarterial embolization via the ophthalmic artery was not achieved. The superior ophthalmic vein was partially thrombosed and an attempt at its surgical isolation was unsuccessful. In this patient, transorbital puncture of the cavernous sinus allowed complete obliteration of the fistula and resulted in prompt resolution of symptoms.