Treatment of Carotid Cavernous Fistulas

Abstract

The treatment of a carotid cavernous fistula (CCF) depends on the severity of the clinical symptoms, its angiographic characteristics, and the risk it presents for intracranial hemorrhage. In most instances, endovascular treatment is preferred.High-flow direct CCFs usually are traumatic or are caused by rupture of a cavernous aneurysm into the sinus, but a small percentage can be spontaneous. They usually present with sudden development of a clinical triad: exophthalmos, bruit, and conjunctival chemosis. All direct CCFs should receive treatment, because they carry a high probability of intracranial hemorrhage or neurologic deterioration.Low-flow indirect or dural CCFs, either incidental or with minimal symptoms, are not associated with significant risk of intracranial hemorrhage. The accepted practice is to treat ocular symptoms conservatively with medical management or manual carotid compression. If the patient cannot tolerate the symptoms, or if signs of ocular morbidity occur, endovascular treatment is offered.The first treatment option should be endovascular embolization with a combination of detachable balloons, coils, stents, or liquid embolic agents. The procedure can be performed from either an arterial or venous approach. Use of these materials and techniques can yield a high cure rate with minimal complications.If the patient is not amenable to embolization or if the embolization fails, then surgery (surgical ligation of the internal carotid artery or packing of the cavernous sinus) should be offered.Stereotactic radiosurgery may be an elective treatment for low-flow CCFs, but it has no role in the treatment of high-flow CCFs.

Carotid-cavernous fistulas

“…5,17,42,52,88 This is demonstrated both clinically by reversal of the signs and symptoms of the CCF and angiographically by fistula obliteration with reversal of retrograde cortical venous flow and vascular steal. In a series of more than 200 patients presenting with posttraumatic direct CCFs, Higashida et al 26 reported complete fistula occlusion with preservation of the ICA in 88% of patients.…”

“…10, 17,18,62 When conservative management is used, it is important to have close ophthalmological follow-up, with serial vision tests, intraocular pressure measurements, and funduscopic examinations. 49 Progressive visual decline, papilledema, and refractory elevation of intraocular pressure are all indications for emergency endovascular intervention.…”

“…Other small series of patients with indirect CCFs have shown long-term obliteration of the fistula after treatment with radiosurgery in 75%-100% of patients. 3,17,28,53,64 Radiosurgery should not be used in emergency cases, as there is a latency of several months to years before complete obliteration of the CCF is accomplished. …”

“…Some practitioners have reported 100% obliteration rates in small series. 9,17,66,79 Tu et al 79 reported a series of 19 patients in whom direct surgical intervention was used after endovascular treatment failed. Closure of the CCF was achieved in all 19 patients, with a 73% ICA patency rate.…”

New daily persistent headache — rare primary or secondary phenomena caused by carotid-cavernous fistula? A case report

“…The usual clinical presentation of a direct high-flow CCF appears as a consequence of high-pressure arterial blood transmitted directly into the cavernous sinus and ophthalmic veins, leading to venous hypertension [7], which can include a various presentations such as proptosis, chemosis, conjunctival injection, cranial nerve pareses, and visual deficits, bleeding (from mouth, nose, or ears), and cerebral complications (intracranial hemorrhage, increased intracranial pressure, and steal phenomena) [8].…”