DIRECT CAROTIDO-CAVERNOUS FISTULA - CLINI CAL, RADIOLOGICAL AND THERAPEUTIC STUDIES IN 49 CASES

Materials and Methods : From 1977 to 1996, 49 direct carotido-cavernou s fistulae were studied among the sixty some cases diagnosed over thes e 20 years. Five were caused by spontaneous rupture of an intracaverno us aneurysm and the others were caused by trauma. Results: The clinica l presentation in 37 patients was exophthalmia with pulsating conjunct ival hyperhemia and vascular murmur. Some cases had a neurological syn drome suggesting cavernous involvement. A bilateral presentation was o bserved in 2 cases. One patient had no ophthalmologic syndrome but had a vascular murmur. Prior to 1982, all patients were treated and cured by occlusion of the internal carotid after direct access via the neck using a 3 F Fogarty catheter. Since 1982, patients have been treated with the detachable balloon technique. The carotid was preserved in 16 cases. In one case, secondary thrombosis occurred due to major dissec tion. In one case, the size of the breach was too small for the balloo n so a coil was used. In one other case? insertion of the guide wire a nd catheter was sufficient to occlude the fistula. There was one death during treatment due to fistula rupture and one partially regressive right hemiplegia which could not be explained. This patient also devel oped left hemiplegia two years later, again with no explaining cause. Cure was achieved in the other patients without sequellae. Discussion: Direct carotido-cavernous fistulae due to rupture of an aneurysm or t rauma are uncommon. When flow through the breach is minimal, vascular treatment may not be necessary unless clinical signs appear since this type of fistula heals spontaneously. In other cases, an endovascular balloon procedure is indicated. There are few complications. Embolizat ion with coils or other devices should only he used in selected cases when the breach is too small for the balloon.