Dural carotid cavernous sinus fistula: outcome after endovascular treatment or conservative management

Abstract

PurposeTo analyze the efficacy of endovascular treatment and conservative management in patients with dural arteriovenous sinus fistula.MethodsRetrospective and observational study, including patients with dural carotid cavernous fistula followed at Ophthalmology and Neuroradiology departments of Hospital Santa Maria – Lisbon between 1991 and 2019. Patient demographics, risk factors, symptoms, etiology, angiographic findings and clinic outcome were studied.ResultsNineteen patients were included. 53% were female and mean age at diagnosis was 64 years (range from 10 to 78). Atherosclerosis risk factors were identified: hypertension (79%), diabetes (21%) and hyperlipidemia (21%). Ocular symptoms were the only presentation of the disease, with proptosis and hyperemia being the main clinical signs. Bilateral fistula was found in 16%. Spontaneous fistula occurred in 81% and trauma history was identified in 19%. %. According to Barrow angiographic classification, 11% were grade B, 21% C and 58% D. Endovascular treatment by transvenous/transarterial embolization was performed in 79% (n = 15), 73% with complete exclusion in a mean of 8.6 ± 17.4 months. The mean follow‐up was 4.0 ± 3.1 years after procedures. Conservative management was performed in 21% (n = 4) and the last follow‐up was 3.5 ± 5.0 years. In both groups, most patients (65–75%) showed symptoms and ophthalmologic examination improvement. After endovascular treatment, visual acuity was maintained (0.7 ± 0.4), and there was intraocular pressure reduction (25.1 ± 6.5 to 15.0 ± 2.3 mmHg). In patients with conservative management, there was no change in visual acuity (0.4 ± 0.5) and intraocular pressure decreased with medication (29.3 ± 9.5 to 19.3 ± 9.2 mmHg). Secondary ocular hypertension (25%) was a long‐term complication of carotid cavernous sinus fistulas.ConclusionsOcular symptoms are the most frequent presentation of dural carotid cavernous fistula, with ocular hypertension as the commonest complication. In less symptomatic patients, the risks and benefits of endovascular treatment should be considered, as conservative treatment may be an option.