Spontaneous Dural Carotid-Cavernous Fistula Treated with Microcoil Insertion

This report includes a case of a 65-year-old woman presenting with a spontaneous dural carotid-cavernous fistula. Biomicroscopic examination of the anterior segment showed significant conjunctival chemosis, dilatation of the episcleral vessels, narrow anterior chamber, and a proptosis of the right eye, whereas the fellow eye was unremarkable. Retinal examination revealed an impaired arteriovenous ratio (A/V) from 1-4 to 1-2 and two extensive cotton exudates. An ultrasound scan (US) demonstrated congestion of the upper ophthalmic vein. Selective brain angiography through right femoral catheterization revealed a dural fistula of the wall of the cavernous right sinus. The patient underwent surgery on the superior ophthalmic vein and insertion of a micro-catheter in the cavernous sinus under CT guidance. Furthermore, a trans-femoral catheter was placed in the carotid artery on the same side as the fistula to allow arteriographic controls after micro coil positioning and embolization. Angiographic follow-up immediately after positioning the coils showed the occluded fistula and a regular flow circulation between the internal and the external carotid arteries. After treatment, the patient presented a complete resolution of symptoms. Conservative management is effective and safe in treating patients with carotid-cavernous fistula and mild clinical features because of a good chance of spontaneous or secondary thrombosis after arteriographic occlusion.