Endovascular management of direct carotid-cavernous sinus fistulas

To evaluate the single-centre experience with endovascular management of direct carotid-cavernous sinus fistulas (DCCF). Between November 2008 and November 2010, a total of 14 patients (11 males) with direct carotid-cavernous sinus fistula underwent 16 transarterial treatment sessions. The patient files and angiograms were analysed retrospectively. Clinical signs and symptoms included exophthalmos [n=12, (85.7%)], pulsatile tinnitus [n=9, (64.3%)], cranial nerve III or VI palsy [n=2, (14.3%)], and impaired vision [n=1, (7.1%)]. Angiography revealed in addition cortical drainage in five patients (35.7%). Transarterial embolization was performed using detachable balloon in nine sessions (56.2%), detachable coils in three sessions (18.8%) and a combination with Onyx in four sessions (25%). Complete interruption of the arteriovenous shunt was achieved in all patients. There was a tendency for ocular pressure-related symptoms to resolve rapidly, while cranial nerve palsy and diplopia improved slowly (7.1%) or did not change (7.1%). The patient with visual impairment recovered within the first two weeks after endovascular treatment. After complete interruption of the arteriovenous shunt, two (12.5%) recurrences were observed in balloon treatment and retreatment was given. Transarterial management is a highly efficient and safe treatment in DCCFs. In the majority of patients a significant and permanent improvement in clinical signs and symptoms can be achieved.