Embolization of bilateral cavernous sinus dural arteriovenous fistulas via the ascending pharyngeal artery using the "pressure cooker" technique: A case report.

Bilateral cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) are uncommon, and transarterial embolization (TAE) via the pharyngeal trunk of the ascending pharyngeal artery (AphA) has rarely been reported.

Methods: A 59-year-old female presented with a 1-month history of mild headache. On physical examination, no positive signs were found. Digital subtraction angiography revealed bilateral CS DAVFs. TAE via the pharyngeal trunk of the AphA using the "pressure cooker" technique was performed. After the distal pharyngeal trunk was catheterized with a Marathon microcatheter, the pharyngeal trunk was coiled, and the "pressure cooker" effect was established. The Onyx-18 liquid embolic system was administered, effectively obliterating most of the bilateral CS DAVFs. A small residual left fistula was embolized via the middle meningeal artery (MMA) and accessory meningeal artery (AMA). Postoperatively, the patient suffered an asymptomatic infarction of the head of the caudate nucleus due to Onyx migration into the intracranial artery and minor paralysis of the left side of the face due to injury to the cranial nerve branches of the MMA and AMA. One month later, the patient appeared to have recovered well. For bilateral CS DAVFs, TAE via the pharyngeal trunk of the AphA may be selected when the transvenous route is occluded and when the AphA route is easily accessible. The "pressure cooker" technique was helpful.

Conclusions: In select cases, bilateral CS DAVFs can be embolized via the pharyngeal branch of the AphA. However, possible stroke from dangerous anastomoses must be considered.