Dural carotid cavernous sinus fistula: Ocular characteristics, endovascular management and clinical outcome

Abstract

Objective: To describe the ocular findings, endovascular treatment, and clinical outcome in patients with dural carotid cavernous sinus fistula (CCF). Material and Method: A retrospective evaluation of 80 consecutive patients who underwent examination and treatment for dural CCF between January 1997 and December 2004 was performed. Results: Fifty females and 30 males, with an average age of 49 years (from 6 -80 years) participated in this study. All patients had more than one clinical signs and symptoms including proptosis (84%), arterialization of conjunctival vein (93%), chemosis (42%), cranial nerve palsy (52%), elevated intraocular pressure (51%), and optic neuropathy (13%). Diminished vision was found in 43% of the patients. The degree of visual deficit ranged from 20/40 to no light perception. After angiographic evaluation, patients were classified to CCF Barrow's type B 14%, type C 15%, and type D 71 %. Endovascular treatment by transvenous and/or transarterial embolization was performed in 60 patients (75%). Carotid-angular compression therapy was solely performed in 19 patients (24%) and was used as an adjunct to endovascular treatment in 30 patients (38%).The follow-up period ranged from 6 to 94 months. Clinical cure was achieved in 41 patients (51%) and improvement in 30 patients (38%). Anatomical cure was demonstrated by angiogram in 50 patients (63%). Intra-operative complications were found in three patients including ophthalmic artery occlusion and cerebral infarction. Eight patients experienced transient aggravation of symptoms including increased proptosis, elevation of intraocular pressure, choroidal detachment that required suprachoroidal drainage, and venous stasis retinopathy. Ophthalmic vein thrombosis resulting in central retinal vein occlusion was developed in three patients and finally caused severe visual deficit. There was no operative mortality. Conclusion: Selective management with endovascular therapy and manual compression are the effective treatment for dural CCF. However, sight-threatening complications can develop after therapy due to progressive ophthalmic vein thrombosis and should be carefully monitored.