Title: Endovascular Treatment of Carotid Cavernous Fistulae: A Study of Management and Outcome
Authors: Dr Bharatkumar Mudalgi, Dr Manohar Kachare, Dr Manish Shrivastava, Dr Akshay Kulkarni
DOI: https://dx.doi.org/10.18535/jmscr/v5i7.135
Abstract
Background: Carotid cavernous fistulae (CCF's) are spontaneous or acquired communications between the carotid artery and the cavernous sinus and are commonly associated with acute visual loss. The presenting complaints depend upon size, location, duration of fistula and presence or absence of collaterals. These fistulas are classified on the basis of etiology, hemodynamic features, or the angiographic appearance. Various noninvasive modalities used for diagnosis include computed tomography, CT or MR angiography and doppler studies. Cerebral angiography is the gold standard test for carotid cavernous fistulae. Endovascular treatment of these lesions is becoming increasingly popular for definitive management of these fistulae. We undertook this study to determine site and type, vascular approach for effective management and efficiency of endovascular management of carotid-cavernous fistula.
Aims and Objective: (1) To determine the efficiency of endovascular management of carotid-cavernous fistula.(2) To determine the site and type of carotid-cavernous fistula by the means of diagnostic conventional/ digital subtraction angiography. (3) To determine the vascular approach for effective management of the fistula (4) complete cure of the carotid-cavernous fistula.
Materials and Methods: This was a prospective cohort study consisting of 60 patients diagnosed with carotid cavernous fistula. The clinical presentation was established for each patient. Clinical symptoms, signs were noted down. All patients underwent a diagnostic angiography. Angiographic findings were noted with a special emphasis on location, type, relation of fistula to carotid and presence of collaterals. All patients underwent a diagnostic angiogram prior to treatment. Endovascular treatment was done according to standard protocol. Mostly balloon occlusion of the fistula site with or without coil embolisation was done in direct type of fistula. Post procedure patient was observed for symptomatic response and thus accomplishment of pre-therapeutic goals. Outcomes of the procedure were graded as. (1) Complete cure. (2) Improvement but with residual pathology. (3) Procedure abandoned. (4) Complications. The follow- up protocol included clinical examination at 1-3 month's interval and the following year.
Results: The analyses of demographic data revealed that out of 60 patients 41 (68.33%) were males and 19 (31.66%) were females with a M: F ratio being 1:0.46. The youngest and oldest patient was 6 yrs and 68 yrs old respectively with a mean age 37 years. Direct fistula was more common in males (37/41) while indirect fistula (12/19) was found to be more common in females. Traumatic Fistulas were more common in males (36/41) while spontaneous fistulas were more common in females (15/19). The common symptoms associated with CCF’s were Proptosis (96%), redness of eyes (75%) and diplopia (33%). Least common symptoms were diminished vision (23%) and pain (11%). Common signs were conjunctival injection and restricted extra ocular muscular movements which were seen in 75% patients each. Frequency of venous drainage pattern in patients revealed that most common drainage was through ipsilateral superior opthalmic vein. Endovascular treatment was done in 2 sessions in majority of the cases (27/60) while only 1 patient needed more than 5 sessions. Most of the patients (75%) were treated by trans arterial route while 7 patients (11.66%) was treated by transvenous route while 8 patients (13.33%) were treated using transarterial as well as transvenous route. Most common embolisation material used was balloons and coils. Glue and PVA was used in 4 and 1 patients respectively. The results of endovascular treatment were found to be excellent with 42/60 (70%) patients getting completely cured. There was improvement in symptoms but with residual pathology in 12/60 (20%) patients while complications occurred and procedure was abandoned in 2 patients each. Spontaneous closure of fistula was seen in 2 patients.
Conclusion: Endovascular management of Carotid cavernous fistulae (CCF’s) is becoming increasingly popular. In acute setting this can be a life saving procedure. Complete cure either angiographic or symptomatic is significant following a proper plan and use of appropriate therapy in least probable sessions.
Keywords: Carotid cavernous fistulae, Angiography, Endovascular treatment, Outcome.
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Dr Bharatkumar Mudalgi
Associate Professor Department of Radiodiagnosis,
Government Medical College, Miraj (MS) India