Endovascular treatment options for carotid-cavernous fistulae

Abstract

A carotid-cavernous fistula is a pathological shunt between the internal or external carotid arteries and the cavernous sinus (CS). The arteriovenous shunt can be direct, between the internal carotid artery and the CS, or indirect, between meningeal branches from the carotid arteries and the dural coverings of the CS. Direct fistulas occur most commonly after craniofacial trauma, while indirect shunts result from various chronic diseases. Signs and symptoms depend on the venous drainage routes. Exophthalmos, chemosis, and diplopia are caused by venous drainage through the superior and inferior ophthalmic veins. If venous egress is mainly through the inferior petrosal sinus, patients complain of pulsatile tinnitus. Cortical venous drainage is the most dangerous route because it can lead to focal neurological deficits and intracerebral haemorrhage. Treatment of carotid-cavernous fistulae can be achieved through different endovascular techniques, using detachable balloons, coils, liquid embolic agents, covered stents, and flow-diverters. This paper aims to report three cases with carotid-cavernous fistulae, which were successfully cured using different transarterial and transvenous modalities.