Endovascular treatment of carotid cavernous sinus fistula: A systematic review

Table 1 Carotid cavernous sinus fistula

Symptoms and signs

Exophthalmos, proptosis

Cephalic bruit

Conjunctival chemosis, ‘’red eye’’

Pain, headache

Trigeminal nerve dysfunction

Elevated intraocular pressure, secondary glaucoma

Diminished visual acuity, visual loss

Subconjunctival hemorrhages

Corneal damage

Intracranial hemorrhage

Otorrhagia

Epistaxis

Differential diagnosis

Vascular pathologies

Marginal sinus fistulas (with a restriction of venous drainage via the jugular bulb)

Anomalous intracranial venous drainage (sigmoid sinus hypoplasia/aplasia)

Cavernous sinus thrombosis

Intraorbital lesions

Fibrous dysplasia

Frontal sinus mucocele

Ocular neoplasms

Osteoma

Hemangioma

Inflammatory, allergic and infectious pathologies

Conjunctivitis

Endocrine pathologies

Thyroid ophthalmopathy

Indications for emergency treatment

Angiographic findings

Pseudoaneurysm

Large varix of the cavernous sinus

Venous drainage to cortical veins

Thrombosis of distant venous outflow pathways

Clinical signs and symptoms

Increased intracranial pressure

Rapidly progressive proptosis

Intracerebral, subarachnoid and external hemorrhage

Transient ischemic attack

Treatment modalities

Conservative management (manual compression therapy and medical therapy)

Surgical management

Stereotactic radiosurgery

Endovascular management

Direct fistula

Transarterial treatment (preferred approach for direct CCF)

Detachable balloon occlusion

Transarterial coil and material embolization

Covered stent graft placement (endovascular reconstruction of the parent artery)

Parent artery occlusion

Transvenous treatment

Transvenous detachable coil embolization

Liquid embolizing agents (n-BCA, Onyx)

Indirect fistula

Transvenous treatment (preferred approach for indirect CCF)

Transvenous detachable coil embolization

Liquid embolizing agents (n-BCA, Onyx)

Transarterial treatment

Transarterial coil and material embolization

CCF: Carotid cavernous sinus fistula; n-BCA: n-butyl 2-cyanoacrylate.