CORRESPONDENCE posed by a primitive foramen lacerum medius, a fusion of the Letter: Coiling of a Carotidocavernous Fistula FO with the foramen lacerum, which may occur in up to 4% of via the Foramen Ovale: 2-Dimensional the population. Injury to the cavernous ICA has been reported Operative Video to cause direct C-C fistula and ischemic complications. Placing To the Editor: a temporary occlusion balloon in the cavernous ICA prior to We observed with interest the surgical video by Brinjikji accessing the cavernous sinus, as described by Gil et al, may be a et al demonstrating direct puncture of the foramen ovale (FO) helpful maneuver in the event of penetrating injury to the ICA. for coiling an indirect carotidocavernous (C-C) fistula. The Therefore, with fluoroscopic guidance and experience in authors were not successful in obtaining transvenous access to the utilizing the Mullan-Lichtor technique, direct CS puncture via cavernous sinus. As a salvage measure, the authors percutaneously FO appears to be a safe salvage technique for those rare cases in accessed the FO to enter the cavernous sinus using a modification which a C-C fistula cannot be accessed via standard techniques. of the Mullan-Lichtor technique, which was described in 1983 for percutaneous treatment of trigeminal neuralgia. Disclosure Gil et al were the first to modify the Mullan-Lichtor technique The authors have no personal, financial, or institutional interest in any of the for the treatment of indirect C-C fistula. As the authors described drugs, materials, or devices described in this article. in the video, a 14-gauge needle was used to enter the FO. The Rimal Hanif Dossani, MD stylet was retrieved and a 20-gauge spinal needle, preshaped with Devi Prasad Patra, MD a15 curve in its distal portion, was introduced though the trocar Hugo Cuellar, MD, PhD to pierce the external dural layer of the cavernous sinus. A micro- Department of Neurosurgery catheter was advanced into the cavernous sinus over a 0.012-inch Louisiana State University Health Sciences Center 3 3 nitinol guidewire. Gil et al placed an endovascular balloon in Shreveport, Louisiana the cavernous internal carotid artery (ICA) to safeguard against erroneous entry into the cavernous ICA through the FO; however, the balloon was never inflated as the cavernous sinus was accessed without complication. REFERENCES In this letter, we aim to highlight neurovascular complica- 1. Brinjikji W, Sorenson T, Atkinson J, Cloft H, Lanzino G. Coiling of a caroti- tions of percutaneous cavernous sinus access through the FO. docavernous fistula via the foramen ovale: 2-dimensional operative video. Oper Fluoroscopic guidance avoids erroneous access to foramina other Neurosurg. 2017, published online ahead of print: November 2, 2017 (doi: 10.1093/ ons/opx224). than the FO. Still, unintended access of other foramina other 2. Mullan S, Lichtor T. Percutaneous microcompression of the trigeminal ganglion than the FO along the skull base may cause injury to traversing for trigeminal neuralgia. J Neurosurg.1983;59(6):1007-1012. neurovascular structures. Relative to the FO, an anterosuperior 3. Gil A,López-Ibor L,Lopez-Flores G,Cuellar H,Murias E,Rodríguez-Boto G. Treatment of a carotid cavernous fistula via direct transovale cavernous sinus trajectory leads to the inferior orbital fissure whereas a posteroin- 4 puncture. JNeurosurg. 2013;119(1):247-251. ferior trajectory to the jugular foramen. The most feared compli- 4. Tew J, Morgan C, Grande A. Percutaneous stereotactic rhizotomy in the treatment cation is cannulation of the ICA, indicated by pulsatile blood flow of intractable facial pain.In : Quinones-Hinojosa A, ed. Schmidek and Sweet: from the needle. The ICA can be entered in 3 locations: (1) the Operative Neurosurgical Techniques 2-Volume Set: Indications, Methods and Results. Philadelphia, PA: Saunders; 2012: 1409-1418. C2 (petrous) segment in the carotid canal posterior to the FO, (2) the C3 (lacerum) segment in the foramen lacerum postero- medially, and (3) the C4 (cavernous) segment in the cavernous 10.1093/ons/opx283 sinus. Injury to the ICA at the C3 segment may be predis- OPERATIVE NEUROSURGERY VOLUME 14 | NUMBER 4 | APRIL 2018 | E51 Downloaded from https://academic.oup.com/ons/article-abstract/14/4/E51/4840661 by Ed 'DeepDyve' Gillespie user on 16 March 2018
Operative Neurosurgery – Oxford University Press
Published: Apr 1, 2018
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