ABSTRACT
Cavernous sinus dural arteriovenous fistula (DAVF) was a special type of intracranial vascular malformation, and endovascular treatment was usually the first choice. However, sometimes it might fail for patients without the proper approach. Video 1 illustrates the case of a patient who presented with left exophthalmos and conjunctival hyperemia caused by cavernous sinus DAVF. Transarterial and transvenous embolization have been attempted but unsuccessful due to no pathways to the fistula. The orbital symptoms aggravated gradually. Therefore we performed combined microsurgical and endovascular treatment in a hybrid neurovascular operating room through direct puncture of caverous sinus by craniotomy and subsequent embolization. A zygomatic-pterional approach was used with epidural exposure of anterior clinoid process and cavernous sinus. After precise localization of the cavernous sinus, we directly punctured it until the blood spurted. An Echelon-10 microcatheter was inserted into cavernous sinus assisted by a Synchro microwire without any resistance. Microcathether angiography confirmed that it was in the true cavity of the cavernous sinus. Curative embolization was achieved successfully using coils and Onyx-18, and no procedure-related complications occurred. The orbital signs and symptoms significantly relieved after surgery and did not relapse at 6-month follow-up. Endovascular treatment remained the optimal choice for cavernous sinus DAVF. However, for practical cases without accessible pathways, combined microsurgical and endovascular management in a hybrid neurovascular operating room was feasible, although challenging. The patient gave informed consent for the procedure and video production.
