European Journal of Radiology Extra 68 (2008) 9–11 Case report of endovascular therapy of indirect dural carotid-c fistula using PVA microspheres Petar Bo ˇ snjakovi ´ c a , Dragan Stojanov a,∗ , Saˇ sa Risti ´ c a , Ivan Stefanovi ´ c b , Neboj ˇ sa Stojanovi ´ c b , Anica Pavlovi ´ c b a Institute of Radiology Clinical Center Niˇ s, Bul. Dr. Zorana Djindjica 48, 18000 Niˇ s, Serbia b Clinic for Neurosurgery Clinical Center Niˇ s, Bul. Dr. Zorana Djindjica 48, 18000 Niˇ s, Serbia Received 20 February 2008; accepted 6 May 2008 Abstract Carotid-cavernous fistulae (CCF) are spontaneous or acquired connections between the carotid artery and the cavernou Type D are fistulas between meningeal branches of both the internal and external carotid artery and the cavernous sinus accompani symptoms. Current treatment options are endovascular. We report successful treatment of such carotid-cavernous fistula of internal maxillary artery using Bead Block spheres. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Carotid-cavernous fistula; Endovascular therapy; PVA microspheres 1. Introduction CCF are spontaneous or acquired connections between the carotid artery and the cavernous sinus. They are classified as directand indirect [1,2].Various classifications of CCF have been proposed. The classification scheme established by Barrow et al. [3] is used frequently and divides CCFs into 4 angiographic types with different sources of dural supply. Type D are fistulas between meningeal branches of both the internal and external carotid artery and the cavernous sinus. In another two major classifications of dural arteriovenous shunts (DAVS), the prin- cipal divider is between shunts that have or have not cortical venous reflux (CVR), i.e., retrograde flow of arterial blood into the pial venous system [4,5]. Durall CCF are found most com- monly in elderly women, without a definable precipitating factor. Clinicalpresentation of type D includes various ophthalmic symptoms such as proptosis, chemosis, arterialized conjuctival veins,ocular paresis, retroorbital pain and diminished visual acuity [6,7]. Current treatment of type D CCFs is endovascular: transarterial, transvenous or combined, using coils, PVA parti- cles and liquid adhesives [8]. We describe successful treatment of our patient with type D CCF by transarterial embolization of ∗ Corresponding author. Tel.: +381 631094197; fax: +381 18221469. E-mail address: stojanovd@ptt.yu (D. Stojanov). external carotid artery branches using Bead Block micro (Terumo-Europe Co.). 2. Case report One month before admission, A.M. a 57-year-old woman gradually developed diplopia, exophthalmus and conjuctival injection (Fig. 1). At the time of admission, the patient pre- sented with right exophthalmus, visual disturbances, diplopia, rightabducensand rightoculomotorius palsy.Diagnostic angiography revealed Barrow type D CCF with arterial sup- ply via meningeal branches of the rightinternal maxillary artery (Fig. 2) and the left internal carotid artery. After selec- tive catheterization of the right external carotid artery using 5F diagnostic catheter, microcatheter was placed coaxially and introduced into the maxillary artery. Embolization was performed using 2 ml of Bead Block microspheres in range 100–300 ␮m. Embolization resulted in complete occlusion the anterior branches of the internal maxillary artery ( Fi 3). Symptoms and signs of fistula gradually disappeared dur the nextmonth (Fig. 4). There wasno recurrence of the clinical signs in the next 14 months. Control angiography formed at that time showed no communication of the cav sinuswith any ofthe arterial intracranial vascularterrito- ries. 1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.05.007