When the Plan
Changes
Why complex cerebrovascular surgery requires more than knowing how to perform a procedure. It requires knowing when to change course.
In cerebrovascular neurosurgery, the same diagnosis doesn’t always mean the same treatment. Anatomy can change what’s possible — and sometimes the most important decision a surgeon makes is recognizing when the standard approach isn’t the right one.
Guilherme Barros, MD, a fellowship-trained neurosurgeon specializing in complex cerebrovascular conditions at Atlantic Brain and Spine, recently treated a patient whose case demonstrated exactly why that matters.
Progressive eye redness, bulging and double vision that had previously been attributed to less serious eye conditions.
A carotid cavernous sinus fistula (CCF), an abnormal connection between blood vessels behind the eye.
The patient’s anatomy made the standard minimally invasive route to the fistula impossible.
A Diagnosis That Needed Treatment
The patient, a man in his late 60s, had been experiencing worsening redness, bulging and double vision. Other specialists had suggested allergies or a mild eye condition. When Dr. Barros evaluated him, he recognized that something more serious was happening.
He had a carotid cavernous sinus fistula, or CCF — an abnormal connection between the internal carotid artery and the venous system behind the eye. Left untreated, the resulting pressure can threaten vision and increase the risk of stroke.
CCFs are treatable. For most patients, treatment begins with a well-established minimally invasive approach. But first, the surgeon needs to understand exactly how that individual patient’s blood vessels are configured.
“Neurosurgery is about decision-making. As surgeons, we must understand the anatomy, know the options, and recognize when we need to take a different approach to treat our patients safely and effectively.”— Guilherme Barros, MD
The Standard Plan Wasn’t Going to Work
The angiogram didn’t just confirm the diagnosis. It revealed something that changed the treatment plan.
Map the anatomy. Treat through the blood vessels.
Typically, a catheter angiogram is performed through an artery in the groin or wrist. When the anatomy allows, tiny catheters can then be guided through the vascular system to embolize and close the fistula.
The usual route could not reach the fistula.
The patient’s venous drainage made the standard transfemoral or transradial approach impossible. Rather than force a route that wasn’t viable, Dr. Barros needed another way in.
A Different Route to the Same Goal
The angiogram showed an indirect Barrow type B fistula supplied by multiple small arterial branches into the cavernous sinus and superior ophthalmic vein. The way those veins drained ruled out the conventional route.
Dr. Barros had another option: reach the fistula through the superior ophthalmic vein using a transorbital approach. Instead of navigating through blood vessels that could not provide a workable path, the team could access the vein through a small incision in the eyelid and approach the fistula directly.
The goal did not change. The route did. Direct access allowed the team to reach and embolize the abnormal connection when the standard vascular pathway could not.
The procedure required coordination across specialties. Plastic surgeon Daniel Pyo, MD, at Morristown Medical Center exposed the superior ophthalmic vein through a small eyelid incision. Dr. Barros then performed the intracranial transvenous embolization, placing coils to shut down the abnormal blood flow.
The Change in Plan Changed the Outcome
The procedure took less than two hours. Within a week, the patient’s double vision was gone, the redness had almost completely resolved and the eyelid incision was minimally visible.
Complex Cases Need More Than One Option
The technical success of the procedure was only part of this patient’s outcome. What came first was recognizing that the conventional approach would not work — and having the training, experience and resources to offer another one.
This case marked the first time the transorbital approach had been performed at Morristown Medical Center. Bringing that capability to the region gives patients another option when complex anatomy makes a more conventional treatment path impossible.
For patients with complex cerebrovascular conditions, expertise is not simply knowing how to perform a procedure. It is knowing which approach fits the individual anatomy — and when the plan needs to change.
Expert Care Starts Here
Connect with Atlantic Brain and Spine to discuss your diagnosis, treatment options or a second opinion with our neurovascular team.
