title: Dural carotid cavernous fistula: definitive endovascular management and long-term follow-up.
abstract: OBJECTIVE
  To describe the endovascular treatment and clinical outcome in patients with indirect carotid cavernous fistulas (CCFs) over a 15-year period. To our knowledge, this is the largest series in the medical literature.
  
  
  METHODS
  Interventional case series.
  
  
  METHODS
  A retrospective evaluation of 135 consecutive patients who underwent examination and treatment for indirect CCF was performed. Patients received independent evaluations by ophthalmologists, neurologists, or neuro-ophthalmologists before, during, and after endovascular treatment. Patients initially received noninvasive imaging followed by cerebral arteriography for definitive diagnosis and stratification by angiographic risk factors. Endovascular treatment was performed in 133 (98%) patients and clinical follow-up was achieved in 135 (100%) patients on an average of 56 +/- 4.3 months (range: 2 months-14 years). Angiographic follow-up was performed in 72 (54%) patients with ongoing symptoms or a history of fistula with high-risk angiographic features. Arteriographic cure with long-term clinical outcome is summarized by modified Rankin scale (mRS) and Barthel index (BI).
  
  
  RESULTS
  At a mean follow-up of 56 months, 121 (90%) patients were clinically cured. At latest clinical follow-up, 131 (97%) patients showed good recovery (mRS, 1-2; BI 90-100), one (1%) had moderate disability (mRS, 3; BI, 50-60), and three (2%) (mRS, 4; BI, 40-50) were severely disabled. Procedure-related permanent morbidity was 2.3%. There was no operative mortality.
  
  
  CONCLUSIONS
  With the observed favorable outcomes and low rate of procedural morbidity in this patient population with long-term angiographic and clinical follow-up, endovascular therapy should be the primary treatment for patients with indirect (dural) fistulas of the cavernous sinus.
authors.affiliation: Department of Radiology, Neurointerventional Division, University of California at San Francisco, USA. pmm2002@columbia.edu
authors.forename: Philip M
authors.initials: PM
authors.lastname: Meyers
authors.forename: Van V
authors.initials: VV
authors.lastname: Halbach
authors.forename: Christopher F
authors.initials: CF
authors.lastname: Dowd
authors.forename: Todd E
authors.initials: TE
authors.lastname: Lempert
authors.forename: Adel M
authors.initials: AM
authors.lastname: Malek
authors.forename: Constantine C
authors.initials: CC
authors.lastname: Phatouros
authors.forename: James E
authors.initials: JE
authors.lastname: Lefler
authors.forename: Randall T
authors.initials: RT
authors.lastname: Higashida
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015901:Angiography, Digital Subtraction; D002339:Carotid Arteries / Q000000981:diagnostic imaging; D020216:Carotid-Cavernous Sinus Fistula / Q000175:diagnosis / Q000628:therapy*; D002533:Cerebral Angiography; D004621:Embolization, Therapeutic; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011247:Pregnancy; D012189:Retrospective Studies; D016896:Treatment Outcome