Transvenous embolisation of spontaneous carotid-cavernous fistulas by sequential occlusion of the cavernous sinus

There are two important pathological features associated with carotid-cavernous fistula (CCF): the retrograde cortical venous drainage that can cause intracranial haemorrhage and non haemorrhagic neurological deficit and the retrograde ophthalmic venous drainage that causes orbital venous congestion and visual impairment. We propose a sequential embolisation strategy by the selective occlusion of these two pathological features as the initial steps followed by occlusion of the rest of the cavernous sinus. Eight patients with spontaneous CCF were treated by transvenous embolisation using our embolisation strategy. The clinical features, angiographic findings, embolisation procedures, and clinical and angiographic outcomes were analyzed. The follow-up period ranged from one to 21 months. Clinical cure was achieved in six patients at one to two month follow-ups. One patient with bilateral CCFs had clinical cure of the right eye and clinical improvement of the left eye at three-month follow-up. Another patient had clinical cure at one-month follow-up except residual VI nerve palsy. Two patients had complete angiographic obliteration of the fistula immediately after the embolisation procedure. Another three patients underwent follow-up angiography at one to 16 months and all showed angiographic cure. There were no immediate or late complications. Our embolisation strategy offers a safe and effective option in the embolisation of spontaneous CCF as demonstrated by the clinical results of our eight patients.