Endovascular Treatment of Orbital Lesions
Neil M. Borden, MD
Mazen H. Khayata, MD†
Bruce L. Dean, MD
Richard A. Flom, MD
Adel M. Medhkour, MD‡
Burton P. Drayer, MD
Robert F. Spetzler, MD‡
Division of Neuroradiology, ‡Division of Neurological Surgery, Barrow Neurological Institute, Mercy Healthcare Arizona, Phoenix, Arizona
†Current address: Arizona Heart Institute, Phoenix, AZ
During a 2-year period, 17 patients with vascular abnormalities that involved the orbital contents were evaluated. Nine patients had carotid-cavernous sinus fistulae (CCSF) (6 direct, 3 indirect). Three patients had orbital cavernous venous malformations, two patients had traumatic arteriovenous fistulae, two patients had orbital-facial arteriovenous malformations, and one patient had a large olfactory groove meningioma supplied by the ophthalmic artery. All patients, except for two with asymptomatic venous malformations, underwent endovascular therapy. The nine patients with CCSFs and the two untreated patients with venous malformations are excluded from discussion. The remaining six patients underwent endovascular treatment, which included direct puncture and ophthalmic artery embolization. A multidisciplinary approach (surgery, radiation, or both) was used in four of the six patients. Favorable outcomes were achieved in all six patients, and no neurologic complications resulted from the endovascular procedures. A wide variety of vascular lesions may involve the orbit directly or indirectly. Endovascular techniques can be helpful in treating these lesions, which often require a multidisciplinary approach to achieve the most satisfactory results. Under proper conditions, direct puncture techniques and superselective ophthalmic artery embolization may be employedin treatment protocols.
Key Words: arteriovenous malformation, carotid-cavernous sinus fistula, endovascular, meningioma, ophthalmic artery, orbit
Endovascular treatment has emerged as an innovative and effective method for treating vascular lesions of the central nervous system (CNS). This technique, however, has not yet been used in many CNS locations that have delicatestructures. One such frontier, the orbit, has been avoided in lieu of more conservative approaches to treatment.Advances in guidewire and microcatheter technology, in addition to improved digital-subtraction angiography (DSA) and road-mapping techniques, now allow the surgical neuroangiographer to navigate previously unreachable territories with limited risk. It is possible to place microcatheters into the ophthalmic artery distal to the central retinalartery—a placement that is a prerequisite to safe embolization.[3,9,10]
Embolization can be useful in definitive (primary) treatment, as well as being an adjunct to surgery and radiation in treating vascular abnormalities of the orbital contents. A variety of vascular malformations can occur in the orbit, including high-flow arteriovenous malformations (AVMs), slow-flow dural-vascular malformations, and cavernous-venous malformations. Carotid-cavernous sinus fistulae (CCSF) can involve the orbit indirectly via orbital venous drainage.[2,11] Orbital and peri-orbital neoplasms parasitizing blood flow from orbital arteries can also occur. Although endovascular treatment of such lesions is possible under safe conditions using proper techniques, embolization through the ophthalmic artery can be a contraindication to treatment because of the danger of inducing blindness by occluding the retinal artery. However, if the microcatheter can be placed distal to the central retinal artery, embolization through this route can be performed cautiously. Unfortunately, the extreme tortuosity of the ophthalmic artery may preclude distal catheterization and embolization via this route. Symptomatic orbital cavernous-venous malformations can be treated with low morbidity by direct puncture and injection of a sclerosing agent. This article summarizes our experience in treating a variety of vascular lesions involving the orbital contents.
Methods and Materials
Between April 1992 and August 1994, 17 patients with vascular lesions involving the orbital contents were evaluated by the Endovascular Service. Their medical records and imaging studies were reviewed retrospectively. Of the 17 patients, 9 had CCSFs: 6 patients had direct CCSFs and 3 patients had indirect CCSFs (dural AVMs). All 17 patients, except two with asymptomatic orbital venous malformations, were treated by endovascular methods. The nine patients with direct and indirect CCSFs and the two untreated asymptomatic patients with orbital cavernous-venous malformations are excluded from further discussion. The remaining six patients underwent diagnostic angiography and endovascular treatment (Table 1). A multidisciplinary approach utilizing surgery, radiation, or both was used to treat four of these six patients (Table 2).
All angiograms and endovascular treatments were performed using DSA and road-mapping techniques. Of the six patients, five (Cases 1, 2, 4, 5, and 6) underwent angiography and embolization via a transfemoral, transarterial approach. Three patients (Cases 1, 2, and 3) underwent direct puncture of their lesions using 21- (Cases 1 and 2), 22-, and 23-gauge (Case 3) butterfly needles. In Cases 2, 3, and 4, the lesions were embolized by different combinations of Tracker 10 and Tracker 18 (Target Therapeutics, Freemont, CA) microcatheters in conjunction with Seeker, Dasher, and Taper microguidewires (Target Therapeutics, Freemont, CA). A variety of embolic agents were used in each case (Table 1). Orbital signs and symptoms of five of the six patients showed a marked overlap (Table 1). In contrast, the patient (Case 4) who had a large olfactory groove meningioma exhibited no orbital symptoms related to her lesion.