Dural fistulae of the cavernous sinus and interventional neuroradiology. Apropos of 4 cases

PURPOSE: Our purpose was to show how difficult it is to diagnose a dural fistula of the cavernous sinus, which is an anomalous arteriovenous shunt within the dura mater extending from meningeal arteries to the cavernous sinus. CASE REPORT: A dural fistula was suspected in four female patients aged between 61 and 80, presenting with a red eye, dilated episcleral veins, exophthalmos and elevated intraocular pressure. A cerebral hyperselective angiography was performed in all cases. RESULTS: The cerebral angiography confirmed the diagnosis of a dural fistula in all cases, showing the early filling of the cavernous sinus followed by the draining vessel (posterior in case n. 4, anterior in cases n degrees 1, 2, 3). Case n degrees 2 was unilateral and cases n. 1, 3, 3 were bilateral. The blood flow was low in all cases. A successful embolization was performed in all patients with resolution of all symptoms. CONCLUSION: The diagnosis of dural fistulas is often difficult because of misleading clinical signs. It is documented by a cerebral angiography showing the feeding vessels and helping to choose either venous or arterial embolization which is the most suitable treatment.     

Embolization of carotid-cavernous fistulae. Technique and results of surgery

Seventy two patients with carotid cavernous fistula (CCFs) were managed at our hospital during fifteen year period. Transarterial treatment of CCFs using the detachable balloon technique was performed in all patients resulting in clinical and angiographic cure in 68 patients. Fatal outcome in two patients. Surgical ligation of the internal carotid artery was needed also in two patients.     

Radical resection of meningiomas and arteriovenous fistulas involving critical dural sinus segments: experience with intraoperative sinus pressure monitoring and elective sinus reconstruction in 10 patients

OBJECTIVE: Radical resection of meningiomas and dural arteriovenous fistulas involving functional major dural sinuses entails the risk of intracranial hypertension and venous infarction. Surgical reconstruction of dural sinuses and bridging veins increases the spectrum of dural sinus conditions that can be treated by complete resection, but indications for venous reconstructions and associated risks are still not well defined. We report our experience with sinus reconstruction based on the intraoperative assessment of collateral venous flow. METHODS: Radical resection of meningiomas (n = 5) or dural arteriovenous fistulas (n = 5) involving critical segments of dural sinuses was performed in 10 patients. All but two patients were suffering from recurrent disease after incomplete treatment. Tolerance of sinus occlusion was assessed intraoperatively by measuring stump pressure in the superior sagittal sinus during test clamping of the involved sinus segment. RESULTS: In five patients, the results of pressure monitoring suggested that occlusion of the sinus might not be tolerated. In two other patients, major bridging veins entered the diseased segment. In these patients, the resected sinus segment was reconstructed and bridging veins were reinserted as far as possible. Postoperative graft occlusion occurred in two patients. One patient who was managed without reconstruction sustained a transient postoperative neurological deficit resulting from venous congestion in the vein of Labbé. Postoperative imaging confirmed total elimination of the pathological process in all 10 patients. There was no recurrence of disease during follow-up periods of up to 8 years. CONCLUSION: The monitoring of sinus pressure, together with the possible reconstruction of the diseased sinus, allows complete surgical treatment of dural sinus abnormalities and involves acceptable risk.     

Orbital venous approach to the cavernous sinus: an analysis of the facial and orbital venous system

Carotid-cavernous fistulas are abnormal communications between the internal carotid artery and the cavernous sinus produced by a rupture of the wall of the carotid artery or one of its branches into the sinus. Extradural branches of the internal or external carotid arteries may communicate with the cavernous sinus, producing proptosis, progressive glaucoma, and ocular vascular engorgement. Various approaches to obliterate these fistulas have evolved, many of which carry high morbidity or are precluded by anatomical considerations. Analysis of the venous anatomy of the orbit and face, including human cadaver dissections, reveals a new and safe approach to the cavernous sinus, requiring microsurgical isolation and cannulation of the superior ophthalmic vein through an anterior orbital approach. Selective embolization of a carotid-cavernous fistula can be performed successfully through this route. We present pertinent anatomy and technical considerations and the successful clinical application of these principles. Surgeons familiar with craniofacial anatomy and microvascular techniques can apply these principles and play an active role in the treatment of these complex problems.     

Preventive effects of an antiallergic drug, pemirolast potassium, on restenosis after percutaneous transluminal coronary angioplasty

PURPOSE: Radiosurgery is an effective treatment for cerebral arteriovenous malformations. We conducted the present study to investigate the feasibility and efficacy of gamma knife radiosurgery for dural arteriovenous fistulas (DAVFs) of the cavernous sinus. METHODS: Eighteen patients (12 women and six men; 29-75 years old [mean age, 55 years]) with DAVFs of the cavernous sinus (Barrow's type B:1, C:7, and D:10) treated by gamma knife radiosurgery were enrolled in the study. DAVFs were bilateral in six patients and unilateral in 12. Stereotactic X-ray angiography and MR imaging were performed for targeting the radiosurgery. Areas of arteriovenous communication targeted for irradiation were first outlined on the X-ray angiograms. The target regions were then transferred to and displayed on the MR images. Dose planning was based on findings on the integrated images. Prescribed maximum target doses were 22 to 38 Gy (mean, 28 Gy). The targets were covered by 50% to 90% isodose levels. Radiation doses to the surrounding optic apparatus were kept to less than 8 Gy. The patients were followed up with color Doppler sonography and MR imaging. When noninvasive imaging suggested obliteration, X-ray angiography was performed to verify the results. RESULTS: The DAVFs were totally obliterated in 12 (80%) of the 15 patients. In the other three, one was almost completely obliterated at 14 months and two were partially obliterated at 19 and 27 months, respectively, after radiosurgery. No complications or symptom worsening occurred during the follow-up period. CONCLUSION: Gamma knife radiosurgery is a feasible, effective, and safe treatment for DAVFs of the cavernous sinus. Integration of stereotactic X-ray angiography and MR imaging not only aids treatment efficacy but also protects the relevant vital structures, especially the optic apparatus, from the hazards of radiation.     

Endovascular surgical approach to intracranial vascular diseases

PURPOSE: The endovascular surgical approach to complex disorders of the central nervous system has made rapid and significant advancements over the past decade. Patients with intracranial arterial aneurysms, traumatic carotid and vertebral artery lesions, including fistulas and pseudoaneurysms, hemodynamically significant atherosclerotic lesions, vasospasm, and acute stroke are now being approached and treated by newer and less invasive techniques, including cerebral angioplasty and thrombolytic therapy. METHODS: All procedures are usually performed from a transfemoral approach utilizing a variety of occlusion devices, including detachable silicone balloons, microcoils, electrolytic detachable coils, liquid tissue adhesives, and particulate emboli for vessel occlusion. For dilatation and reperfusion of vessels, balloon angioplasty catheters, stents, and thrombolytic drugs are being used. RESULTS: For the treatment of traumatic vascular injuries, such as carotid cavernous sinus fistulas and vertebral arteriovenous fistulas and pseudoaneurysms, endovascular therapy has become the treatment of choice. The endovascular approach for intracranial aneurysms is emerging as a therapeutic option in selected cases. For occlusive disorders in patients presenting with acute cerebral ischemia, extracranial angioplasty and cerebral thrombolysis techniques are currently under investigation. CONCLUSIONS: As these techniques continue to evolve, the field of interventional neuroradiology will expand the therapeutic options for managing complex cerebrovascular disorders and improve patient outcome in acute stroke therapy.     

Epileptic seizures in patients with multiple sclerosis. Is the prognosis of epilepsy underestimated?

Spinal arteriovenous malformations are uncommon disorders associated with considerable difficulty in diagnosis and treatment. They are divided into dural arteriovenous fistulas and intradural medullary spinal cord angiomas. In this retrospective series of six patients the clinical outcome of embolization is presented. The patient material consisted of three dural fistulas and three cord angiomas, one of which bled causing sudden paresis, pain and incontinence. In the remaining five patients the symptoms were progressive consisting of paraesthaesias, paraparesis, pain and incontinence. The clinical status of four patients was not changed after the treatment, one deterioriated and one improved. There were no bleedings after the therapy. In one patient spinal angiography for follow-up was performed and recanalization was seen in the dural fistula after particle embolization. Also, in one cord angioma embolized with particles reflow appeared in the immediately repeated angiography. For permanent angioma occlusion tissue adhesive is preferred as embolic material. Surgical therapy as an alternative or adjuvant to embolization is discussed with a review of the literature. Early timing of the therapeutic intervention is stressed to avoid the development of irreversible ischaemic medullopathy and to prevent haemorrhage. The therapeutic procedures at the early stage of the disease may be curable or, at least, halt the progression of the symptoms. Cross-sectional imaging studies and myelographies may reveal the lesion. For the definitive diagnosis of spinal angioma with its vascular feeders and for the evaluation of its occlusion grade after the therapy selective spinal angiography is needed.     

Use of preoperative computed tomography-angiography in cranial remodeling: technical note

OBJECTIVE/IMPORTANCE: One of the most severe complications of craniosynostosis repair is dural sinus laceration. Massive hemorrhage and air embolism are potentially life-threatening sequelae that can result from such an event. The aberrant anatomy of patients with craniosynostosis only accentuates this risk, because separation of the calvaria from the underlying dura is often performed without direct visualization of the sinuses. METHODS: Three-dimensional computed tomography was combined with computed tomographic angiography in the preoperative assessment of patients with craniofacial abnormalities. RESULTS: A clear understanding of the dural sinus anatomy in relation to the overlying bony landmarks became available to the operating surgeon. Six patients underwent this procedure, with excellent visualization of the bony and sinus anatomy achieved in all cases. CONCLUSION: It is thought, that the benefit of combining these procedures has been significant by allowing the visualization of the dural sinus anatomy and overlying bony landmarks. This procedure conveys minimal concomitant morbidity or expense to the patient, yet offers valuable insight toward operative planning and complication avoidance.     

MR diagnosis of cerebrospinal fluid fistulas using a 3D-CISS sequence

PURPOSE: We compared a new MR method for diagnosis of CSF fistulas with CT cisternography. MATERIAL AND METHODS: In a prospective case study we examined 35 patients with posttraumatic CSF fistulas and compared the results with the intraoperative findings. The MR investigation was performed using a 1.0T whole body MR-system. We used a strongly T2*-weighted 3D-CISS sequence. The examinations were performed in prone position, in patients with severe CSF rhinorrhoea additionally in supine position. RESULTS: The sensitivity and specificity of the MR method (88.9% and 95.1%) is higher compared with CT cisternography (77.8% and 87.8%). The reason for the lower sensitivity of CT compared with MRI are complex fracture systems, involving several paranasal cavities in patients with false positive results in CT cisternography. Reasons for the lower specificity of CT cisternography are false negative results in patients with small dural lesions below 2 mm2. CONCLUSION: Using a new method MRI can detect CSF-fistulas. The MR method is superior to CT cisternography, is noninvasive, the administration of contrast and agent is no longer necessary.     

Histopathological aspects of dural arteriovenous fistulas in the transverse-sigmoid sinus region in nine patients

OBJECTIVE: In recent years, dural arteriovenous fistulas (DAVFs) have been primarily thought to be acquired lesions, formed after sinus thrombosis. The pathogenesis of DAVF, however, is still controversial. We have studied histopathological aspects of DAVFs in resected specimens obtained from nine patients, to obtain clues to the pathogenesis of DAVFs. METHODS: Histological comparison was made among nine DAVF cases and five control cases without venous sinus disease. In addition, the relationship between the clinical course and histological aspects was investigated. RESULTS: The essential abnormality found was a connection between the dural arteries and the dural veins within the venous sinus wall, through small vessels averaging approximately 30 microns in diameter. By using several staining methods, we confirmed that the vessels were part of the venous system; we named these dilated venules "crack-like vessels." CONCLUSIONS: The development of abnormal communications between dural arteries and dural veins (crack-like vessels) is regarded as the essential part of the pathogenesis of DAVFs, and sinus thrombus is not thought to be an essential lesion of DAVFs. It might be postulated that sinus hypertension caused by stenocclusive disease of the venous sinuses triggers the development of fistulous connections between arteries and veins in the dural wall, which may result in increasingly dilated venules and the formation of DAVFs.     

Vertical transmission of hepatitis C virus infection

BACKGROUND: Cavernous carotid aneurysms are generally benign entities. Certain indications exist for their treatment, however, including transient ischemic events, subarachnoid hemorrhage or risk of subarachnoid hemorrhage, epistaxis or its risk, ophthalmoplegia, pain, and progressive visual loss. We feel certain angiographic features may indicate a greater likelihood that cavernous carotid aneurysms extend into the subarachnoid space, thus making their rupture a life-threatening event. METHODS: A case report of an intracavernous carotid aneurysm, which at surgery extended into the subarachnoid space, is described. RESULTS: In this particular case, deformation of the aneurysm (waisting) as seen at angiography was in retrospect an indication that the cavernous carotid aneurysm extended into the subarachnoid space, either through the dural ring or through the eroded dural roof of the cavernous sinus. This finding was verified at surgery when the lesion was explored and trapped. CONCLUSION: Angiographic waisting of a cavernous carotid aneurysm may indicate that the aneurysm extends into the subarachnoid space. Such extension means that rupture would be a life-threatening event. While deformation of the aneurysm may be secondary to compression against the optic nerve or anterior clinoid process with an intact layer of dura overlying the aneurysm, the neurosurgeon confronted with such findings should analyze such lesions carefully and consider surgical exploration.     

A normal sagittal spinal configuration: a desirable clinical outcome

OBJECTIVE: To review our experience of 9 patients who had attempted suicide by swallowing alkaline substances. DESIGN: Retrospective study. SETTING: Two university hospitals, Finland. PATIENTS: During the years 1987-1996. 9 patients who had swallowed more than 100 ml of strong alkali. RESULTS: 2 patients with oesophagorespiratory fistulas of the four with third degree injuries died in hospital, the first died of overwhelming sepsis and the second of multiple organ failure. The other two survived emergency staged resection and subsequent reconstruction. Delay between swallowing the alkali and the initial operation, and development of oesophagorespiratory fistulas were the most important predictors of death. Four patients with second degree injuries underwent oesophageal resection and reconstruction after they had developed oesophageal strictures. Two of these six survivors developed anastomotic strictures after reconstruction, both of which necessitated repeated oesophageal dilatations. One patient with a first degree injury was treated conservatively. CONCLUSIONS: An early and aggressive approach to severe third degree corrosive injuries of the upper gastrointestinal tract is needed to resect all necrotic tissue and to make it possible to do a successful reconstruction later. The development of oesophagorespiratory fistulas requires immediate attention, whereas first and second degree injuries can be treated after the patient has been stabilized.     

Multiple dural arteriovenous fistulas

Four patients with multiple intracranial dural arteriovenous fistulas (DAVFs) at separate sites were treated by endovascular techniques (transarterial and/or transvenous embolization), surgery (excision or isolation), radiotherapy, or combinations, according to the pathophysiological condition. All lesions in two patients were obliterated completely without neurological deficit. There were residual fistulas after the treatment in two patients, but these were low-grade lesions without retrograde cortical venous drainage, and marked clinical improvement was obtained. Planning of treatment strategies for multiple DAVFs requires careful analysis of the venous drainage from the affected sinuses and cerebral hemodynamics.     

Sacral agenesis and caudal spinal cord malformations

Thirty-three children and one adult with sacral agenesis (SA) were studied by computed tomographic myelography and/or magnetic resonance imaging and were monitored for a mean period of 4.7 years. Four children had the OEIS (concurrent omphalocele, cloacal exstrophy, imperforate anus, and spinal deformities) complex, and three others had VATER (vertebral abnormality, anal imperforation, tracheoesophageal fistula, and renal-radial anomalies) syndrome. All patients shared some of the characteristic features of SA, namely, a short, intergluteal cleft, flattened buttocks, narrow hips, distal leg atrophy, and talipes deformities. Neurologically, lumbosacral sensation was much better preserved than the motor functions, and urinary and bowel symptoms were universal. The level of the vertebral aplasia was correlated with the motor but not with the sensory level. The important neuroimaging findings of SA were as follows: 1) 12 patients (35%) had nonstenotic, tapered narrowing of the caudal bony canal, and 2 patients had hyperostosis indenting the caudal thecal sac; 2) 16 patients (47%) had nonstenotic, tapered narrowing and shortening of the dural sac, but 3 patients (9%) had true, symptomatic dural stenosis, in which the cauda equina was severely constricted by a pencil-sized caudal dural sac; 3) the coni could be divided into those ending above the L1 vertebral body (Group 1, 14 patients) and those ending below L1 (Group 2, 20 patients). Thirteen of 14 Group 1 coni were club or wedge-shaped, terminating abruptly at T11 or T12, as if the normal tip was missing. All 20 Group 2 coni were tethered: 13 were tethered by a thick filum; 2 were extremely elongated and had a terminal hydromyelia; 3 were terminal myelocystoceles; and 2 were tethered by a transitional lipoma. High blunt coni were highly correlated with high (severe) sacral malformations (sacrum ending at S1), but low-lying tethered coni were highly correlated with low sacral malformations (S2 or lower pieces present).(ABSTRACT TRUNCATED AT 400 WORDS)     

Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: technical case report

OBJECTIVE AND IMPORTANCE: The endovascular treatment of carotid-cavernous dural fistulae is becoming the prominent treatment modality for these lesions. The intractability of these lesions and their tendency to recur, especially after previous endovascular treatment sessions, exhausts the available routes and tends to present a difficulty in accessing the cavernous sinus. To avoid the risks associated with a direct surgical approach, an alternative, less invasive route to the cavernous sinus using a pretemporal extradural approach is combined with a direct endovascular approach. CLINICAL PRESENTATION: A 38-year-old woman presented with a history of right visual and ocular symptoms related to a Type D cavernous carotid dural fistula, which was fed by internal carotid and external carotid branches. The fistula was initially treated with embolization of the external carotid arterial supply. After a transient improvement, the patient's visual acuity worsened. A follow-up angiogram showed the major supply from the intracavernous internal carotid branches and draining through the inferior ophthalmic vein. The transvenous route was not accessible. An attempt to cannulate the intracavernous branches was not successful. The combined pretemporal and endovascular approach was then used. INTERVENTION: The pretemporal extradural region of the superior orbital fissure was exposed. Using microsurgical techniques and Doppler flow guidance, the anterior cavernous sinus was cannulated through the orbital venous drainage channels. Using intraoperative angiography, thrombogenic coils were deployed at the level of the fistula. Intraoperative angiography confirmed complete obliteration of the fistula. CONCLUSION: The combined pretemporal (extradural) and endovascular approach to the cavernous sinus is a less invasive alternative for the treatment of intractable carotid-cavernous dural fistulae.     

Urinary fistula after transplantation: eleven cases

OBJECTIVES: To specify the anatomical features of urinary fistulas and to evaluate the results of percutaneous and surgical treatment of post-transplantation urinary fistulas. PATIENTS AND METHODS: 11 urinary fistulas were observed after 160 renal transplantations, corresponding to an incidence of this complication of 6.8%. Urinary fistulas were treated percutaneously in three cases and surgically in eight cases. THE FOLLOWING COMPLICATIONS WERE OBSERVED DURING SURGICAL TREATMENT: extensive necrosis of the urethra in four cases, rupture of the sutures in two cases, a punctate pelvic fistula in one case. RESULTS: The incidence of fistula was 5.8% for Leadbetter reimplantation and 8.1% for Lich-Gregoir extravesical reimplantation. We obtained one success in three patients treated percutaneously and one death and seven successes out of eight patients treated surgically. We performed ureteropelvic anastomosis with the native ureter in the case of extensive necrosis of the ureter (4 cases), a new reimplantation in three cases and suture of the pelvic fistula in one case. CONCLUSION: More than one half of post-transplantation urinary fistulas observed in our department are secondary to ischaemic necrosis of the ureter. We emphasize the value of preservation of the ureteric blood supply during organ harvesting. Post-transplantation urinary fistulas must be treated surgically, as soon as possible, to avoid infectious complications.     

The apolipoprotein(a) promoter contains a retinoid response element

OBJECTIVE AND IMPORTANCE: Dural arteriovenous fistulas of the superior sagittal sinus (SSS) account for 8% of intracranial dural fistulas. Their association with a thrombosis of the posterior part of the SSS is rare. In such cases, the usual neurosurgical and endovascular approaches cannot provide a good technical solution for treatment of the lesion, and a combined neurosurgical and neuroradiological approach is therefore needed. CLINICAL PRESENTATION: A 68-year-old man presented with rapidly evolving dementia. Cerebral angiography revealed a dural arteriovenous fistula of the SSS associated with thrombosis of the posterior part of the SSS. Various endovascular and neurosurgical approaches failed to cure the fistula. INTERVENTION: A burr hole was drilled in the frontal region, in the neurosurgical room. The patient was then transferred to the angiographic room, and the SSS was occluded using free spirals. CONCLUSION: This procedure led to a complete anatomic cure of the fistula, and a slow clinical improvement was observed.     

Irradiation of spontaneous carotid-cavernous fistulas

Two patients with spontaneous carotid-cavernous fistulas were successfully treated with cobalt 60 irradiation to the sellar region. Angiographically, one patient showed combined-type shunts comprising a dural internal carotid-cavernous fistula and a direct internal carotid-cavernous fistula; the other patient had a mixed dural external and internal carotid-cavernous fistula. The respective total radiation dose was 3,200 rads and 3,024 rads. The patients responded satisfactorily to the treatment, with disappearance of the fistulas on angiograms and patency of the internal and external carotid arteries.     

Diagnosis and management of traumatic aorto-right ventricular fistulas

BACKGROUND: Traumatic aorto-right ventricular (Ao-RV) fistulas are rare lesions that result in congestive heart failure if left untreated. Early diagnosis and prompt surgical intervention are required to avoid the natural outcome of cardiac decompensation. METHODS: All cases of traumatic Ao-RV fistula described in the English literature since 1958 were reviewed. The clinical presentation, methods of diagnosis, and treatment strategies were assessed to determine the pathophysiology, natural history, and outcome of surgical intervention. RESULTS: Forty cases of traumatic Ao-RV fistulas were described in the English literature. There were 39 men and 1 woman, with a mean age of 28.3 years (range, 15 to 50 years). Twenty-two (55%) patients had isolated Ao-RV fistulas. Fourteen (35%) had Ao-RV fistulas with aortic insufficiency. Definitive surgical repair was performed in 38 patients. The associated aortic valve injuries were managed with repair techniques or replacement with prosthetic devices. The surgical outcomes in all patients were satisfactory. CONCLUSIONS: The pathophysiology and natural history of Ao-RV fistulas involves the development of congestive heart failure. Traumatic aortic insufficiency frequently is associated with this disorder. Early diagnosis and prompt treatment are necessary to avoid the natural outcome of cardiac decompensation. Definitive repair should be performed with the aid of cardiopulmonary bypass during the same hospitalization.     

Management of cavernous sinus-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein

OBJECTIVE: To describe indications and surgical techniques for embolization of cavernous sinus-dural fistulas (CDF) by passing platinum coils through a cannulated superior ophthalmic vein based on our clinical experience. DESIGN: Retrospective clinical review. SETTING: University tertiary referral hospital and eye institute. PATIENTS: Over a 3-year period, 10 consecutive patients with CDF and progressive orbital congestion underwent transvenous embolization. All patients had a dilated superior ophthalmic vein. All 10 patients had indications for treatment of fistulas on the basis of progressive glaucoma refractory to medical management, venous stasis retinopathy with retinal ischemia, optic neuropathy, diplopia, exophthalmos with exposure keratopathy, cortical venous congestion with risk for intracranial hemorrhage, or a combination of these findings. INTERVENTION: Nine of the 10 patients underwent anterior orbitotomy via a lid-crease or sub-brow incision with cannulation of the ipsilateral superior ophthalmic vein and embolization of the cavernous sinus with platinum coils, following an unsuccessful transarterial embolization. One patient underwent a primary transvenous embolization. MAIN OUTCOME MEASURES: Successful closure of the fistula on angiography, return of baseline visual acuity, normalization of postoperative intraocular pressure, and cosmetically acceptable cutaneous scar. RESULTS: All 10 patients had prompt resolution of symptoms and halt of progressive visual loss following occlusion of the fistulas. Two patients had no flow in the anterior superior ophthalmic vein on angiography suggesting thrombosis, yet the superior ophthalmic vein was easily accessed in the anterior orbit, and transvenous embolization was successfully performed. In 2 additional patients with nondilated superior ophthalmic veins, we were unable to gain surgical access and in 1 case severe bleeding occurred during attempted access of the small vein. CONCLUSIONS: When performed by an experienced orbital surgeon and neuroradiology team, transvenous embolization of CDF via a dilated anterior superior ophthalmic vein is a technically straightforward, safe, and effective treatment for CDF and perhaps should be employed as primary therapy in cases with progressive orbital congestive symptoms. If the superior ophthalmic vein is not dilated or if it is located deep in the orbit, transorbital venous access may not be possible.