'An eye for an eye' therapeutic strategy for cavernous sinus dural arteriovenous fistula: a single-center experience

Background In cavernous sinus dural arteriovenous fistulas (CS-DAVF), ophthalmological symptoms are usually the main clinical presentation, caused by abnormal drainage of the superior ophthalmic vein (SOV). Early opacification of the SOV during cerebral angiography inevitably signifies the fistula's shunt point at the confluence of the SOV and CS. We aimed to leverage this anatomical feature to achieve precise embolization, thereby enhancing the embolization success rate and preventing CS-related symptoms and complications resulting from overpacking.Methods This single-center, case series study was conducted between May 2017 and September 2023, and included the largest sample of CS-DAVF patients treated via the transfemoral vein-SOV approach. We retrospectively reviewed the data of 32 CS-DAVF patients with inferior petrosal sinus (IPS) occlusion.Results The study demonstrated an excellent immediate postoperative complete embolization rate (31/32, 97%). Only three patients (3/32, 9%) developed temporary endovascular treatment-related complications. The average operation time was 131.6 +/- 61.6 min, with an average of 1.2 +/- 1.1 coils and 1.8 +/- 1.2 mL Onyx glue used per patient. CS-DAVF-associated ophthalmological symptoms resolved in all patients. We also identified a rare anatomical variation, where 77% of the patients had a facial vein draining into the external jugular vein.Conclusions Transfemoral vein-SOV embolization should be considered a crucial alternative approach in CS-DAVF patients with occluded IPS and predominantly SOV drainage. This approach showed an excellent immediate postoperative complete embolization rate and satisfactory long-term outcomes along with clinical safety. We therefore strongly advocate for this 'an eye for an eye' treatment strategy.