• Taichi Ishiguro, Tetsu Satow, Akihiro Okada, Eika Hamano, Go Ikeda, Hidekazu Chikuie, Takao Koiso, Naoki Hashimura, Masaki Nishimura, and Jun C Takahashi.
• Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
• World Neurosurg. 2019 Aug 1; 128: 122-126.

BackgroundA spontaneous persistent primitive trigeminal artery-cavernous sinus fistula (PCF) is extremely rare. Until recently, endovascular treatment for PCF involving transarterial and/or transvenous coil embolization of the cavernous sinus (with/without the persistent trigeminal artery) was commonly performed. However, it may result in remaining shunt flow or exacerbation of cranial nerve palsy.Case DescriptionA 51-year-old woman presented with headache and left abducens palsy. Digital subtraction angiography demonstrated a direct fistula between the cavernous segment of the persistent primitive trigeminal artery (PPTA) and posterosuperior compartment of the left cavernous sinus (CS). Three microcatheters were guided into the fistula as follows: 1) through the PPTA to the CS from the left internal carotid artery, 2) through the PPTA to the CS from the basilar artery, and 3) through the CS to the PPTA from the internal jugular vein. Using the double-catheter technique in a multidirectional fashion, shunt occlusion was achieved with a small number of coils. No signs of recurrence were observed during the follow-up period.ConclusionsThe multipronged approach is safe and effective for embolization of a small tortuous artery and shunt segment to avoid incomplete shunt occlusion.Copyright © 2019 Elsevier Inc. All rights reserved.

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