Gamma knife radiosurgery as an alternative treatment of Barr
A 67-year-old man with no past medical history visited our emergency room presenting with acute left orbital pain and double vision in the left eye on December 15, 2017. Ophthalmological examination showed chemosis, conjunctival injection, exophthalmos with mild ptosis, and an intraocular pressure of 23 mm Hg in the left eye. Brain magnetic resonance imaging showed exophthalmos with dilated SOV in the left eye. He was admitted to neurosurgery for interventional neuroradiology under suspicion of CCF.

On December 18, 2017, cerebral angiography was performed. Left internal carotid artery angiography showed a CCF (Barrow type B), which was fed by the meningohypophyseal trunk and drained to the left SOV. Initially, we planned endovascular embolization, but the caliber of the meningohypophyseal trunk was very small, so we thought that a transarterial route was not possible. The transvenous approach via the inferior petrous sinus (IPS) also seemed to be difficult because we could not see the IPS even in the delayed venous phase. Because the patient's condition was not fatal, we thought that surgical exposure via SOV would be invasive considering the complaints. Therefore, we planned GKRS with Leksell Gamma Knife Perfexion (Elekta Instruments, AB, Stockholm, Sweden) for the left cavernous sinus including fistula point as an alternative treatment. The patients received GKRS at 18 Gy to the 50% isodose line based on the radiation dose applied to intracranial arteriovenous malformations on December 22, 2017. The orbital pain disappeared in 2 weeks, and all signs and symptoms in the left eye improved completely within 2 months.

On July 5, 2018, a follow-up angiography was performed that showed complete closure of the fistula with no visible engorged SOV.

Source: Medicine: May 2019 - Volume 98 - Issue 22 - p e15803

Read more:
1 share