title: Endovascular treatment of carotid-cavernous fistulae: Long-term efficacy and prognostic factors.
abstract: BACKGROUND
  Carotid-cavernous fistulae are rare and affect visual prognosis. Their clinical presentation is varied and delayed diagnosis is common. They require rapid neuro-radio-ophthalmologic management.
  
  
  OBJECTIVE
  The goal of this study was to evaluate the long-term efficacy and prognostic factors for treatment of carotid-cavernous fistulas by embolization.
  
  
  METHODS
  A total of 60 patients with direct (10/60, 17%) or indirect (50/60, 83%) carotid-cavernous fistulae suspected during ophthalmological examination underwent cerebral angiography from December 2003 to October 2013. Of these, 59 (59/60, 98%) patients were treated with embolization. Treatment response was assessed with a follow-up angiogram confirming the exclusion of the fistula, and clinically by resolution of the initial symptoms.
  
  
  RESULTS
  The diagnosis was suspected on the basis of proptosis in 45 patients (45/60, 75%), corkscrew episcleral vessels in 38 patients (38/60, 63%), chemosis in 37 patients (37/60, 61%), and diplopia in 30 patients (30/60, 50%). The median delay in diagnosis was 5 ± 5 months [0.5 to 24 months], and mean follow-up was 31 ± 31.5 months [0.5-118 months]. Eighteen patients (18/60, 30%) were lost to follow-up. Clinical response was complete in 24 patients (24/42, 57%) and partial in 14 patients (14/42, 33.5%). Symptoms were stable in one patient (1/42, 2.5%) and worsened in 3 patients (3/42, 7%). Morbidity per procedure was 3.3% and there was no postoperative mortality. Forty patients (40/60, 67%) had radiological follow-up and 39 patients (39/40, 97.5%) had a complete exclusion of the fistula. The presence of diplopia on initial examination was more frequently associated with an incomplete cure (P=0.04).
  
  
  CONCLUSIONS
  The combination of proptosis, corkscrew episcleral vessels and diplopia should rapidly lead to head imaging to search for a carotid-cavernous fistula. Fistula embolization is a safe and effective treatment. The presence of diplopia on initial examination may be associated with a poorer outcome (P=0.044).
authors.affiliation: Oculoplastic surgery department, Foundation Rothschild Hospital, 29, rue Manin, 75019 Paris, France. Electronic address: sofi.stephan@gmail.com.
authors.forename: S
authors.initials: S
authors.lastname: Stéphan
authors.affiliation: Interventional Neuroradiology department, Foundation Rothschild Hospital, 29, rue Manin, 75019 Paris, France.
authors.forename: R
authors.initials: R
authors.lastname: Blanc
authors.affiliation: Oculoplastic surgery department, Foundation Rothschild Hospital, 29, rue Manin, 75019 Paris, France.
authors.forename: M
authors.initials: M
authors.lastname: Zmuda
authors.affiliation: Neuro-Ophthalmology department, Foundation Rothschild Hospital, 29, rue Manin, 75019 Paris, France.
authors.forename: C
authors.initials: C
authors.lastname: Vignal
authors.affiliation: Interventional Neuroradiology department, Foundation Rothschild Hospital, 29, rue Manin, 75019 Paris, France.
authors.forename: M
authors.initials: M
authors.lastname: Barral
authors.affiliation: Interventional Neuroradiology department, Foundation Rothschild Hospital, 29, rue Manin, 75019 Paris, France.
authors.forename: S
authors.initials: S
authors.lastname: Pistocchi
authors.affiliation: Interventional Neuroradiology department, Foundation Rothschild Hospital, 29, rue Manin, 75019 Paris, France.
authors.forename: M
authors.initials: M
authors.lastname: Piotin
authors.affiliation: Oculoplastic surgery department, Foundation Rothschild Hospital, 29, rue Manin, 75019 Paris, France.
authors.forename: O
authors.initials: O
authors.lastname: Galatoire
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D020216:Carotid-Cavernous Sinus Fistula / Q000150:complications / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000628:therapy*; D002533:Cerebral Angiography; D002648:Child; D003131:Combined Modality Therapy; D057210:Delayed Diagnosis; D004172:Diplopia / Q000209:etiology; D004621:Embolization, Therapeutic / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods*; D005094:Exophthalmos / Q000209:etiology; D058447:Eye Pain / Q000209:etiology; D005158:Facial Paralysis / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011379:Prognosis; D012307:Risk Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors
keywords: Carotid-cavernous fistulae; Diplopia; Diplopie; Embolisation; Embolization; Exophtalmie; Exophthalmia; Facteurs pronostiques; Fistule carotido-caverneuse; Prognostic factors; Proptosis; Ptosis