MANAGEMENT OF 100 CONSECUTIVE DIRECT CAROTID-CAVERNOUS FISTULAS - RESULTS OF TREATMENT WITH DETACHABLE BALLOONS

DIRECT CAROTID-CAVERNOUS FISTULAS are high-flow shunts with a direct c onnection between the internal carotid artery and the cavernous sinus. The goals of treatment are to eliminate the fistula and preserve caro tid artery patency. The authors reviewed the outcome of 98 patients wi th 100 consecutive direct carotid-cavernous fistulas initially treated by transarterial embolization with detachable balloons (1979-1992) at the University of Cincinnati Medical Center to evaluate the merits of this technique and to provide a standard for comparison with future t reatment alternatives. Among 100 fistulas, 76 were traumatic in origin , 22 resulted from a ruptured aneurysm, and 2 were iatrogenic. The mos t common presentations were orbital bruit (80%), proptosis (72%), chem osis (55%), abducens palsy (49%), and conjunctival injection (44%). Ei ghty-eight fistulas were successfully occluded in 86 patients with det achable balloon(s), and internal carotid blood flow was preserved in 6 6 patients (75%). Initial attempts at balloon occlusion failed in four patients in whom the fistula eventually closed spontaneously. Five pa tients required direct surgery to occlude the fistula, and two were tr eated with nondetachable balloons; one patient died from injuries sust ained from trauma. The permanent neurological complication rate was 4% , including cerebral infarction in one patient, frontal intracerebral hemorrhage in one patient, and vision loss in another patient. One dea th occurred related to cerebral infarction from a balloon that shifted . Transient ischemia occurred in three patients. On the basis of these results, we conclude that transarterial embolization with detachable balloons provides a high rate of fistula obliteration with low morbidi ty and is the best initial procedure to treat direct carotid-cavernous fistulas.