Selection and combination of techniques for treating spontaneous carotid-cavernous sinus fistulas

Twenty-eight patients with spontaneous carotid-cavernous sinus fistulas (CCFs) were treated using a variety of techniques. Three of four patients with direct CCFs underwent intravascular embolization with a detachable balloon. Embolization with polyvinyl alcohol particles through an external carotid endoarterial route was used in six patients with indirect CCFs, and with ethylene-vinyl alcohol copolymer solution in two. Patients undergoing these conventional treatments, including embolization of the meningeal branches of the external carotid artery, had less satisfactory outcomes. The transvenous approach using minicoils through the inferior petrosal sinus was successful in eight patients. One patient treated using the transvenous approach using copper wire through the ophthalmic vein had worsening of visual acuity and field. Unsuccessful transvenous embolization in four patients required direct surgical exposure and embolization with spring coils. Spontaneous cures occurred in four patients. Direct CCFs with high flow rates were best treated with the detachable balloon or coil technique through a internal carotid endoarterial route. Indirect CCFs were best treated with the minicoil through the inferior petrosal sinus. If these techniques fail, direct surgical exposure allows placement of coils into the cavernous sinus.