Embolisation of dural carotid cavernous sinus fistulas via a vein of the sylvian fissure in two patients

Background. Dural carotid sinus cavernous fistulas account for about 12% of intracranial arteriovenous fistulas. These dynamic shunts are dilemmas not only for the clinical diagnosis but also for the management of ocular complications and in the application of diagnostic and therapeutic techniques. The traditional therapy is transarterial embolisation by an interventional neuroradiologist. We report on the management of two fistulas where the classical therapeutic methods were not possible or failed. Patients and methods. Two patients underwent an osteoplastic pterional craniotomy with cannulation of a vein of the sylvian fissure and controlled embolisation of the fistula with polyvinyl alcohol particles. Results. Successful closure of both arteriovenous shunts was achieved on angiography with normalisation of clinical symptoms. As a severe complication one patient suffered from a stroke after the postoperative angiography. Conclusions. Arteriovenous fistulas not approachable by traditional therapeutic methods, can be embolised effectively via a superficial vein of the sylvian fissure. This surgical route should only be considered if other therapeutic ways fail or seem impossible.