Carotid Cavernous Fistula Treatment & Management

  • Author: Ingrid U Scott, MD, MPH; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 17, 2010
 

Medical Care

  • Exposure keratopathy may be treated with ocular lubricants, and, in severe cases, a tarsorrhaphy may be needed.
  • Glaucoma may require treatment with aqueous suppressants and hyperosmotic agents.
  • Laser peripheral iridectomy may be performed to eliminate the contribution of pupillary block, and cycloplegic agents may be used to encourage a posterior shift of the iris-lens diaphragm.
  • Laser iridoplasty or goniosynechialysis may help further in opening the angle.
  • Proliferative retinopathy and neovascular glaucoma may require panretinal photocoagulation.
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Surgical Care

  • The optimal treatment of a direct carotid-cavernous sinus fistula is closure of the abnormal arteriovenous communication with preservation of internal carotid artery patency. Techniques for achieving this result include surgical repair of the damaged portion of the intracavernous internal carotid artery, electrothrombosis, embolization, or balloon occlusion of the fistula.[3, 4, 5, 6]
  • Dural carotid-cavernous sinus fistulae may close spontaneously, but, for those lesions causing progressive or unacceptable symptoms and signs, standard embolization or endovascular balloon occlusion is generally performed. If these techniques are unsuccessful, direct surgery on the cavernous sinus may be considered. In cases where anatomy makes standard intravascular approach impossible, the superior ophthalmic vein can be cannulated and a balloon or coil threaded into the area of a direct communication.
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Consultations

  • Neurosurgical consultation for management of the carotid-cavernous fistula
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Contributor Information and Disclosures
Author

Ingrid U Scott, MD, MPH  Professor, Department of Ophthalmology and Public Health Sciences, Penn State College of Medicine

Ingrid U Scott, MD, MPH is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Macula Society, Phi Beta Kappa, and Retina Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Stephen D Plager, MD, FACS  Chief, Department of Ophthalmology, Dominican Hospital; Assistant Clinical Professor, Department of Ophthalmology, Stanford University Hospital

Stephen D Plager, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and California Medical Association

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Karaman E, Isildak H, Haciyev Y, Kaytaz A, Enver O. Carotid-cavernous fistula after functional endoscopic sinus surgery. J Craniofac Surg. Mar 2009;20(2):556-8. [Medline].

  2. Yu JS, Lei T, Chen JC, He Y, Chen J, Li L. Diagnosis and endovascular treatment of spontaneous direct carotid-cavernous fistula. Chin Med J (Engl). Aug 20 2008;121(16):1558-62. [Medline].

  3. Kirsch M, Henkes H, Liebig T, et al. Endovascular management of dural carotid-cavernous sinus fistulas in 141 patients. Neuroradiology. Jul 2006;48(7):486-90. [Medline].

  4. Yoon WK, Kim YW, Kim SR, Park IS, Kim SD, Baik MW. Transarterial coil embolization of a carotid-cavernous fistula which occurred during stent angioplasty. Acta Neurochir (Wien). May 5 2009;[Medline].

  5. Wang C, Xie X, You C, Zhang C, Cheng M, He M, et al. Placement of Covered Stents for the Treatment of Direct Carotid Cavernous Fistulas. AJNR Am J Neuroradiol. Apr 2 2009;[Medline].

  6. Bing F, Albrieux M, Vinh Moreau-Gaudry V, Vasdev A. Cavernous sinus fistula treated through the transvenous approach: Report of four cases. J Neuroradiol. Feb 27 2009;[Medline].

  7. de Keizer R. Carotid-cavernous and orbital arteriovenous fistulas: ocular features, diagnostic and hemodynamic considerations in relation to visual impairment and morbidity. Orbit. Jun 2003;22(2):121-42. [Medline].

  8. Debrun GM, Vinuela F, Fox AJ, et al. Indications for treatment and classification of 132 carotid-cavernous fistulas. Neurosurgery. Feb 1988;22(2):285-9. [Medline].

  9. Higginbotham EJ. Glaucoma associated with increased episcleral venous pressure. In: Albert DM, Jakobiec FA, eds. Principles and Practice of Ophthalmology. 2nd ed. 2000: 2781-92.

  10. Ishijima K, Kashiwagi K, Nakano K, et al. Ocular manifestations and prognosis of secondary glaucoma in patients with carotid-cavernous fistula. Jpn J Ophthalmol. Nov-Dec 2003;47(6):603-8. [Medline].

  11. Keltner JL, Satterfield D, Dublin AB, Lee BC. Dural and carotid cavernous sinus fistulas. Diagnosis, management, and complications. Ophthalmology. Dec 1987;94(12):1585-600. [Medline].

  12. Miller NR. Carotid-cavernous sinus fistulas. In: Miller NR, ed. Walsh and Hoyt's Clinical Neuro-Ophthalmology. 4th ed. Baltimore, Md: Williams;1991: 2165-209.

  13. Rai AT, Sivak-Callcott JA, Larzo C, Marano GD. Direct carotid cavernous fistula in infancy: presentation and treatment. AJNR Am J Neuroradiol. Jun-Jul 2004;25(6):1083-5. [Medline].

  14. Troost BT, Glaser JS, Morris PP. Aneurysms, arteriovenous communications, and related vascular malformations. In: Glaser, ed. Neuro-ophthalmology. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins;1999: 589-628.

 
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