Selective transvenous embolization of dural carotid-cavernous sinus fistulas with preservation of sylvian venous outflow

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Abstract
A transvenous embolization technique that spares normal cerebral venous drainage is described. Of 26 dural carotid-cavernous fistulas treated by the authors, in three cases the affected cavernous sinus was supplied by not only the shunt flow but also the sylvian venous drainage. Two patients presented with an abducent nerve palsy and one with an oculomotor nerve palsy in whom selective transvenous embolization of the fistulous portions of the affected cavernous sinus was achieved while preserving of the sylvian venous outflow. Posttransvenous embolization angiograms showed complete occlusion of the fistula in one patient and only small residual shunts in the other two; one underwent subsequent transarterial embolization, whereas the other was followed without additional treatment. The patients' symptoms disappeared between 1 and 2 months posttreatment. Follow-up angiograms revealed that the remnant shunt had disappeared and that the sylvian venous pathway had been preserved. The authors conclude that although the condition is uncommon it is important to recognize that a dural carotid-cavernous sinus fistula, which receives significant sylvian venous outflow, can be treated successfully by selective transvenous embolization of the fistulous compartments in an affected sinus.