Dural carotid cavernous fistula: definitive endovascular management and long-term follow-up

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Abstract

PURPOSE: To describe the endovascular treatment and clinical outcome in patients with indirect carotid cavernous fistulas (CCFs) over a 15-year period. To our knowledge, this is the largest series in the medical literature.

DESIGN: Interventional case series.

METHODS: A retrospective evaluation of 135 consecutive patients who underwent examination and treatment for indirect CCF was performed. Patients received independent evaluations by ophthalmologists, neurologists, or neuro-ophthalmologists before, during, and after endovascular treatment. Patients initially received noninvasive imaging followed by cerebral arteriography for definitive diagnosis and stratification by angiographic risk factors. Endovascular treatment was performed in 133 (98%) patients and clinical follow-up was achieved in 135 (100%) patients on an average of 56 ± 4.3 months (range: 2 months–14 years). Angiographic follow-up was performed in 72 (54%) patients with ongoing symptoms or a history of fistula with high-risk angiographic features. Arteriographic cure with long-term clinical outcome is summarized by modified Rankin scale (mRS) and Barthel index (BI).

RESULTS: At a mean follow-up of 56 months, 121 (90%) patients were clinically cured. At latest clinical follow-up, 131 (97%) patients showed good recovery (mRS, 1–2; BI 90–100), one (1%) had moderate disability (mRS, 3; BI, 50–60), and three (2%) (mRS, 4; BI, 40–50) were severely disabled. Procedure-related permanent morbidity was 2.3%. There was no operative mortality.

CONCLUSIONS: With the observed favorable outcomes and low rate of procedural morbidity in this patient population with long-term angiographic and clinical follow-up, endovascular therapy should be the primary treatment for patients with indirect (dural) fistulas of the cavernous sinus.

Section snippets

Methods

There were 99 (73%) women and 36 (27%) men. Patient age ranged from 18 to 87 years, with a mean age of 60 ± 1.6 (mean ± standard error) years (Figure 1). One hundred twenty-five (93%) patients demonstrated signs of a retroorbital fistula (Table 1). In seven (6%) patients, the onset of symptoms was associated with pregnancy. Two (1.5%) patients presented with hemorrhage associated with high-risk cerebral venous drainage: one cerebral parenchymal hemorrhage and one diffuse subarachnoid

Results

One hundred thirty-three of 135 patients underwent arteriographic evaluation and 179 endovascular procedures for treatment of indirect fistulas of the cavernous sinus. Arterial supply to these fistulas arose from branches of external and internal carotid arteries (Table 2). High-risk cortical venous drainage was present in 41 (31%) patients. A statistically significant correlation between restricted venous drainage patterns and the duration of symptoms was demonstrated (χ2 = 6629, P < .0001).

Case report

A 35-year-old woman (Figure 4) developed pulsatile tinnitus and headache during pregnancy. Over 7 months, she developed progressive bilateral chemosis, proptosis, conjunctival arterialization, and diplopia. The patient had been evaluated with MRI and catheter arteriography and was told that she had a complex dural fistula requiring bilateral craniotomies for treatment. She sought alternatives to craniotomy and was offered an endovascular approach. Arteriography and endovascular surgery was

Discussion

Dural arteriovenous fistulas comprise 10% to 15% of all intracranial vascular malformations.8 Following the transverse-sigmoid sinus, the cavernous sinus is the most common site of involvement. Multiple classification systems have been proposed, but most important is the presence or absence of cortical venous drainage indicative of elevated intracranial venous pressure predisposing to cerebral infarction or hemorrhage. Accurate assessment for cortical venous drainage still requires catheter

Acknowledgements

We thank Daryl Gress, MD; Wade Smith, MD, PhD; David Bonovich, MD; Clay Johnston, MD; J. Claude Hemphill, MD; and the other members of the Neurovascular Neurology Division of the UCSF Medical Center for their significant contribution to the care of these patients.

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