Dural Carotid-Cavernous Fistula Treatment

The aggressive characteristic of dural carotid-cavernous fistula (dCCF) is characterized by elevated intraocular pressure or the presentation of leptomeningeal venous drainage. It is necessary to treat an aggressive dCCF to prevent permanent secondary glaucoma and intracerebral sequelae. The endovascular approach is the treatment modality for dramatic improvement after fistula obliteration. Transvenous catheterizations are performed through the inferior petrosal sinus (IPS) and selection of coil packing within each of the venous drainage channel, such as cavernous sinus (CS)-superior orbital vein (SOV) junction, the connection between the CS and the leptomeningeal vein if there is presence of leptomeningeal drainage. An alternative to the CS and SOV approach can be performed using the transfemoral transvenous or percutaneous approach if cannulation of the IPS fails. Coils are mainly used as the embolic material rather than liquid embolic materials to prevent intracerebral complications and cranial nerve dysfunction. The angiographic endpoint of the endovascular procedure is either subtotal or complete occlusion of the fistula. Any small residual non-aggressive angiographic characteristic can be completely obliterated in a future surgery after routine clinical and radiological follow-up. The results are excellent with a low rate of complications. However, dCCF treatment requires experienced operators with a good understanding of the angiographic architecture and the appropriate skills in endovascular techniques.