Age: 56
Sex: Male
History: 20 yrs ago suffered a traumatic CC fistula treated with common carotid ligation. Over the years, had a grotesque facial deformity due to severe venous congestion. Blind in Rt eye. Complete ophtalmoplegia. 1997, had a Lt cerebellar hemorrhage. Angio showed the CC-fistula draining through posterior aspect of cavernous sinus into superior petrosal veins.

We tried:

1. Intra-op exposure of ICA, introduction of angio catheter, and baloon embo of ICA. Worked very well, but after 30 min, baloon deflated and fistula returned.
2. Could not fix second time around
3. Went to OR. Direct exposure of cavernous sinus, stuffing with 7 cotton balls. Managed to stop cortical venous reflux, but did not kill fistual.
4. Tried a direct (endovascular) trans-venous approach through enlarged superior ophthalmic vein, but could not reach the fistula.
5. Patient went home "cured: of risk of ICH, but not of his fistula.
6. Gary sent me a follow up angio about 6-9 mos later. There is recanalization of the superior petrosal vein drainage into the cerebellum.
7. Back @ square one? What's next?