Abstract
Objectives
To report the epidemiological features, clinical presentation, angiographic characteristics and therapeutic options, success and complication rates in patients with dural carotid cavernous fistulas (dural CCFs).
Methods
Retrospective evaluation of patients followed in our institution between January of 2005 and September of 2013.
Results
There were 38 patients, 76 % females, with an average age of 63 years. Ocular symptoms and signs were the most frequent clinical findings. Dural CCFs were Barrow type B in 8 %, type C in 10 % and type D in 82 %. Cortical venous reflux was present in 50 % of cases. Medical treatment was performed in 16 % of patients, external ocular compression in 8 %, transarterial embolisation in 13 %, transvenous embolisation in 60 % and radiosurgery in 3 %. Clinical and angiographic follow-up data were available in 89 % and 82 % of patients with a mean follow-up time of 9 and 7 months, respectively. Clinical cure was achieved in 58 % of patients and improvement in 24 %. Anatomical cure was demonstrated in 68 %. Transient worsening or new onset of ocular symptoms was observed in 29 %. There was no permanent morbidity or mortality.
Conclusions
In properly selected patients, endovascular embolisation, particularly by transvenous approach, represents a safe and effective treatment for dural CCFs.
Key points
• Dural carotid cavernous fistulas are more common in elderly women
• Dural CCFs most commonly present with ocular symptoms and signs
• Endovascular treatment is effective and safe in properly selected patients
Similar content being viewed by others
References
Preechawat P, Narmkerd P, Jiarakongmun P, Poonyathalang A, Pongpech S (2008) Dural carotid cavernous sinus fistula: Ocular characteristics, endovascular management and clinical outcome. J Med Assoc Thai 91:852–858
Kiyosue H, Hori Y, Okahara M et al (2004) Treatment of intracranial dural arteriovenous fistulas: current strategies based on location and hemodynamics, and alternative techniques of transcatheter embolization. Radiographics 24:1637–1653
Kirsch M, Henkes H, Liebig T et al (2006) Endovascular management of dural carotid-cavernous sinus fistulas in 141 patients. Neuroradiology 48:486–490
Korkmazer B, Kocak B, Tureci E et al (2013) Endovascular treatment of carotid cavernous sinus fistula: a systematic review. World J Radiol 5:143–155
Kim DJ, Kim DI, Suh SH et al (2006) Results of transvenous embolization of cavernous dural arteriovenous fistula: a single-center experience with emphasis on complications and management. AJNR Am J Neuroradiol 27:2078–2082
Davies MA, terBrugge K, Willinsky R, Coyne T, Saleh J, Wallace MC (1996) The validity of classification for the clinical presentation of intracranial dural arteriovenous fistulas. J Neurosurg 85:830–837
van Dijk JM, terBrugge KG, Willinsky RA, Wallace MC (2002) Clinical course of cranial dural arteriovenous fistulas with long-term persistent cortical venous reflux. Stroke 33:1233–1236
Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT (1985) Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg 62:248–256
Stiebel-Kalish H, Setton A, Nimii Y et al (2002) Cavernous sinus dural arteriovenous malformations: patterns of venous drainage are related to clinical signs and symptoms. Ophthalmology 109:1685–1691
Kim MS, Han DH, Kwon OK, Oh CW, Han MH (2002) Clinical characteristics of dural arteriovenous fistula. J Clin Neurosci 9:147–155
Bulters DO, Mathad N, Culliford D, Millar J, Sparrow OC (2012) The natural history of cranial dural arteriovenous fistulae with cortical venous reflux – the significance of venous ectasia. Neurosurgery 70:213–219
Sasaki H, Nukui H, Kaneko M et al (1988) Long-term observations in cases with spontaneous carotidocavernous fistulas. Acta Neurochir 90:117–120
Bink A, Goller K, Lüchtenberg M et al (2010) Long-term outcome after coil embolization of cavernous sinus arteriovenous fistulas. AJNR Am J Neuroradiol 31:1216–1221
Gemmete JJ, Ansari SA, Gandhi D (2009) Endovascular treatment of carotid cavernous fistulas. Neuroimaging Clin N Am 19:241–255
Yoshida K, Melake M, Oishi H, Yamamoto M, Arai H (2010) Transvenous embolization of dural carotid cavernous fistulas: a series of 44 consecutive patients. AJNR Am J Neuroradiol 31:651–655
Agid R, Willinsky RA, Haw C, Souza MP, Vanek IJ, terBrugge KG (2004) Targeted compartmental embolization of cavernous sinus dural arteriovenous fistulae using transfemoral medial and lateral facial vein approaches. Neuroradiology 46:156–160
Ellis JA, Goldstein H, Connolly ES Jr, Meyers PM (2012) Carotid-cavernous fistulas. Neurosurg Focus 32:E9
Roy D, Raymond J (1997) The role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas. Neurosurgery 40:1133–1141
Jahan R, Gobin YP, Glenn B, Duckwiler GR, Viñuela F (1998) Transvenous embolization of a dural arteriovenous fistula of the cavernous sinus through the contralateral pterygoid plexus. Neuroradiology 40:189–193
Koebbe CJ, Singhal D, Sheehan J et al (2005) Radiosurgery for dural arteriovenous fistulas. Surg Neurol 64:392–398
Pollock BE, Nichols DA, Garrity JA, Gorman DA, Stafford SL (1999) Stereotactic radiosurgery and particulate embolization for cavernous sinus dural arteriovenous fistulae. Neurosurgery 45:459–467
Cognard C, Gobin YP, Pierot L et al (1995) Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 194:671–680
Berenstein A, Lasjaunias PL, Ter Brugge K. Dural arteriovenous shunts. In: Berenstein A, Lasjaunias PL, Ter Brugge K (2nd eds). Surgical Neuroangiography. Springer, New York, pp 565–607
Geibprasert S, Pereira V, Krings T et al (2008) Dural arteriovenous shunts: a new classification of craniospinal epidural venous anatomical bases and clinical correlations. Stroke 39:2783–2794
Meyers PM, Halbach VV, Dowd CF et al (2002) Dural carotid cavernous fistula: definitive endovascular management and long-term follow-up. Am J Ophthalmol 134:85–92
Farb RI, Agid R, Willinsky RA, Johnstone DM, Terbrugge KG (2009) Cranial dural arteriovenous fistula: diagnosis and classification with time-resolved MR angiography at 3T. AJNR Am J Neuroradiol 30:1546–1551
Krings T, Geibprasert S, ter Brugge K. Case-based interventional neuroradiology. 1st eds. Thieme, New York pp172–177
Higashida RT, Hieshima GB, Halbach VV et al (1986) Closure of carotid cavernous sinus fistulae by external compression of the carotid artery and jugular vein. Acta Radiol Suppl 369:580–583
Gemmete JJ, Ansari SA, Gandhi DM (2009) Endovascular techniques for treatment of carotid-cavernous fistula. J Neuroophthalmol 29:62–71
Benndorf G, Bender A, Lehmann R, Lanksch W (2000) Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature. Surg Neurol 54:42–54
Lekkhong E, Pongpech S, Ter Brugge K et al (2011) Transvenous embolization of intracranial dural arteriovenous shunts through occluded venous segments: experience in 51 patients. AJNR Am J Neuroradiol 32:1738–1744
Cheng KM, Chan CM, Cheung YL (2003) Transvenous embolisation of dural carotid- cavernous fistulas by multiple venous routes: a series of 27 cases. Acta Neurochir 145:17–29
Klisch J, Huppertz HJ, Spetzger U, Hetzel A, Seeger W, Schumacher M (2003) Transvenous treatment of carotid cavernous and dural arteriovenous fistulae: results for 31 patients and review of the literature. Neurosurgery 53:836–856
Klisch J, Schipper J, Husstedt H, Laszig R, Schumacher M (2001) Transsphenoidal computer-navigation assisted deflation of a balloon after endovascular occlusion of a direct carotid cavernous sinus fistula. AJNR Am J Neuroradiol 22:537–540
Nogueira RG, Dabus G, Rabinov JD et al (2008) Preliminary experience with onyx embolization for the treatment of intracranial dural arteriovenous fistulas. AJNR Am J Neuroradiol 29:91–97
Cognard C, Januel AC, Silva NA Jr, Tall P (2008) Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx. AJNR Am J Neuroradiol 29:235–241
Hu YC, Newman CB, Dashti SR, Albuquerque FC, McDougall CG (2011) Cranial dural arteriovenous fistula: transarterial Onyx embolization experience and technical nuances. J Neurointerv Surg 3:5–13
Lv X, Jiang C, Li Y, Wu Z (2008) Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18. J Neurosurg 109:1083–1090
Elhammady MS, Wolfe SQ, Farhat H, Moftakhar R, Aziz-Sultan MA (2010) Onyx embolization of carotid-cavernous fistulas. J Neurosurg 112:589–594
Lv X, Jiang C, Li Y, Wu Z (2009) Percutaneous transvenous packing of cavernous sinus with Onyx for cavernous dural arteriovenous fistula. Eur J Radiol 71:356–362
Pan HC, Sun MH, Sheehan J et al (2010) Radiosurgery for dural carotid-cavernous sinus fistulas: Gamma Knife compared with XKnife radiosurgery. J Neurosurg 113:9–20
Acknowledgements
The scientific guarantor of this publication is Timo Krings. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding.
No complex statistical methods were necessary for this article. Institutional Review Board approval was not required because it was a retrospective analysis. Written informed consent was not required for this study because it was a retrospective analysis. Methodology: retrospective, observational, performed at one institution.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Rodrigues, T., Willinsky, R., Agid, R. et al. Management of dural carotid cavernous fistulas: a single-centre experience. Eur Radiol 24, 3051–3058 (2014). https://doi.org/10.1007/s00330-014-3339-y
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00330-014-3339-y