Interventional treatment of carotid cavernous fistula

We reviewed retrospectively the outcomes of interventional endovascular treatment of direct or dural (indirect) carotid cavernous fistulas in 24 consecutive patients requiring endovascular treatment at Royal Prince Alfred Hospital between 1994 and 2009. Data was collected from each patient's neurological, ophthalmological and radiological reports. Of the 12 patients with direct fistulas all had signs of orbital and ocular venous congestion and ophthalmoplegia; nine also had reduced vision ranging from 6/9 to nil perception of light, two had normal vision and one was unconscious. Nine of the 12 direct fistulas were embolized transarterially, two transvenously, one by a combination of both approaches and all were successfully closed. After treatment, seven of the nine patients with reduced vision had complete or nearly complete restoration of vision,while two who presented with nil perception of light (one in both eyes) had no recovery of vision. In contrast, seven of the 12 patients with dural fistulas had ophthalmoplegia, three had reduced vision, down to 6/24 and one did not have any sign of venous congestion. Vision recovered in all three patients after embolization of the dural fistula. Dural fistulas were embolized transvenously in 11 and transarterially in one patient. Apart from ophthalmoplegia, all other ocular signs and symptoms rapidly resolved after closure of the fistula in each of the 24 patients. The diagnosis was delayed by being missed either during the first admission or at the first specialist consultation in three of the 12 patients with direct fistulas, and in seven of the 12 patients with dural fistulas. One patient with a direct and another with a dural fistula had limited cerebral infarctions during embolization. In this series, endovascular interventional treatment of carotid cavenous fistulas restored visual loss in 10 of 12 patients with visual loss. The two who did not recover had presented with nil perception of light, one after a delay in diagnosis of 6 weeks. Some degree of ophthalmoplegia tended to remain. This emphasizes the need for early diagnosis and treatment before visual loss or ophthalmoplegia becomes severe.