Surgical Ligation of an Indirect Carotid-Cavernous Fistula With Exclusive Retrograde Cortical Venous Drainage: 2-Dimensional Operative Video.

Indirect carotid-cavernous fistulas (CCFs) are abnormal connections between the cavernous sinus and branches of the internal and external carotid arteries. Indirect CCFs with progressive cortical venous drainage require obliteration to prevent neurological decline secondary to their rupture or progression. While indirect CCFs are often treated with transvenous embolization of their venous outflow through the inferior or superior petrosal sinuses, facial vein, or superior ophthalmic vein, CCFs failing previous embolization may be best treated with surgical ligation. Here we present the case of a 30-year old woman who, 3 years before presentation to our institution, presented with transient monocular blindness to an outside institution. Catheter angiography revealed a CCF without cortical venous drainage which was partially embolized with coils. Catheter angiography at the 1-year follow-up revealed CCF progression characterized by cortical venous drainage into a right cortical vein, basal temporal vein, and the vein of Labbé. The lesion was treated with partial onyx embolization. Two years later, further evaluation at our institution demonstrated cortical venous ectasia-confirming CCF progression. Though asymptomatic, the risk of neurological decline secondary to progression or rupture of the lesion was high given the progressive cortical venous drainage, and treatment was indicated. As the lesion failed endovascular therapy twice, the patient underwent a right pterional craniotomy for surgical disconnection of the CCF's main draining vein and other fistulous connections. The patient had an uneventful recovery, and postoperative catheter angiography suggested complete obliteration of the lesion. Appropriate consent was obtained for the publication of the cadaver's image. The patient consented to the procedure and video recording.