Cavernous Sinus Fistula Access via Occluded SUPERIOR Petrosal Sinus

Case of Dr. Eytan Raz

Yes, yes, sure — there are many examples of this being done via the occluded inferior petrosal sinus (one example here).  Still, to our knowledge, access via occluded superior petrosal sinus — this looks like the first time? Anyone know any different?  If yes give pictures…

Occipital Artery and Ascending Pharyngeal Artery Pages for reference

There are two major outflows — sylvian and superior ophthalmic veins.  Both petrosal sinuses are not draining fistula — however look at DYNA below

Edges of Superior Petrosal Sinus on Cavernous (solid arrow_ and sigmoid (dashed arrow) sides.  Arrowhead is laterocavernous sinus

That’s the way it was, before sinus got occluded by high-flow venopathy (the mechanism by which arterialized veins / sinuses close)

Treatment — transvenous access — Arrow 8F 80 cm, Sofia 6, Headway Duo, Aristotle 14 standard

Venous phase vert injection to best show the patent Sigmoid side of the SPS


A bit more manipulation, and duo is on the arterial side in the posterior clival arcade of the MHT. The fistula pouch is circled in white. 


To be sure, coiling off major venous connections to the pouch.  Probably unnecessary, but don’t want to be painted into corner and leave the sylvian connection open


More superselective embolization cases here