overpacking. The latter can be a problematic matter and appears even in experienced surgical hands not to be completely under control. To prevent overpacking is no less important than avoiding underpacking that will result in persistence of the fistula. These concerns appear to be an inherent problem of direct surgical treatment for DCSFs.

Krisht et al. (1999) described a pretemporal approach to the anterior cavernous sinus for treatment of an “intractable” CS fistula that could not be treated by transvenous approach because of “thrombosis or absence of the petrosal sinuses”. The authors used an extended pterional approach, dissecting the dura in the pretemporal region and drilling the posterior orbital roof to gain access to the anterior extension of the cavernous sinus, where they were able to introduce an atraumatic intravenous cannula. Intraoperative angiography demonstrated complete fistula obliteration after introduction of thrombogenic coils.

The same group (Guerrero et al. 2006) recently reported another case of an “intractable” Type D fistula using a pretemporal direct approach combined with assisted coiling. The patient was reported to have undergone seven unsuccessful attempts at transarterial and transvenous embolization. The authors’ approach represents an elegant surgical technique to overcome the complex anatomy in this region as well as block the fistula flow provided by the ECA branches. In this particular case, however, details of the fistula’s angioarchitecture and why attempts at transvenous catheterizations remained unsuccessful are not reported. The only preoperative image shows an early arterial phase instead of a drainage pattern as erroneously mentioned in the text. All other figures show a stepwise increase of the coil packing. The final arteriogram does not allow one to determine whether complete or subtotal occlusion was achieved with any certainty. No fol- low-up arteriogram was provided. Thus, it remains somewhat questionable whether such “direct open embolization” was indeed indicated, and whether the performed coil packing was sufficient to achieve complete obliteration. Although it is advantageous to be able to target different CS compartments with coils, dense packing may be less easy to achieve while the CS is in fact open and its walls cannot be used as a buttress for the coils.

It can be stated that today so-called “technical challenges” in the EVT of Type D fistulas are mostly manageable with modern transvenous catheterization techniques and sophisticated bi-planar imag-

ing. State-of-the-art endovascular techniques must not be neglected when considering a direct surgical approach in a DCSF. Reported postoperative deficits, particularly with combined operative and technical efforts (general anesthesia, craniotomy, opening of the CS, etc.), have contributed to the current trend of endovascular management (van Loveren et al. 1991) and recently invalidated the need for direct surgical treatment of DCSFs.

In summary, direct surgery, if at all necessary, should be applied in selected cases only to facilitate endovascular approaches. Cooperation between operating and endovascular colleagues is essential for achieving optimal clinical and anatomical results. Current endovascular tools and high-resolution imaging capabilities have minimized the need for direct surgery in the therapeutic management of DCSFs.

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