SPONTANEOUS OCCLUSION OF THE CAROTID-CAVERNOUS FISTULAS. CASE SERIES AND LITERATURE REVIEW

Abstract

Carotid-cavernous fistulas (CCF) is a pathological connection between the arteries and the cavernous sinus, which can be direct or indirect (dural). Direct CCS are characterized by the presence of a direct fistula between the internal carotid artery and the cavernous sinus, while indirect (low-flow) CCS are the result of a pathological connection between the branches of the carotid artery and the cavernous sinus. For more than a century (from the end of the 19th century to the beginning of the 20th century), clinical manifestations and surgical methods of treatment of CCF were discussed. The treatment of patients with indirect shunts and minimal clinical manifestations is not well defined, especially in case where endovascular embolization is associated with technical difficulties considering device selection and difficulties in access to the fistulas, both transarterial and transvenous. Few articles has been studied the tendency of spontaneous occlusion of the CCF ‒ a natural process of recovery. The study of the tendency of the CCS to spontaneous occlusion is promising for optimizing the treatment of this specific group of patients and improving the results of their treatment.Objective ‒ to analyze the cases of spontaneous occlusion of the CCF and data from the literature for optimizing the management of patients with this pathology.Materials and methods. A retrospective analysis of the database of 63 patients with a diagnosis of CCF confirmed by angiography who were treated at the SO «Scientific-Practical Center of Endovascular Neuroradiology NAMS of Ukraine» during the period from 2014 to 2022, was conducted. There were 67 (in 4 patients they were bilateral) patients with CCF. In 7 (11.1 %) cases, their spontaneous occlusion was detected, which was confirmed with follow-up examinations.Results. Among 7 patients with documented spontaneous CCS occlusion, 2 were male and 5 were female. The average age of patients was (56.31 ± 10.39) years. In all cases, CCF were unilateral, dural, low-flow, and occlusion occurred within 3 – 4 months after the manifestation (appearance of clinical symptoms). In 2 (28.6 %) cases, CCF occurred as a result of trauma, in 5 (71.4 %) ‒ they were spontaneous. In 3 (42.8 %) patients, the occlusion occurred before the planned endovascular embolization. In 1 (14.3 %) case, the endovascular treatment was technically unsuccessful, but the CCF regressed after 4 months, which was confirmed by control cerebral angiography. Three (42.8 %) patients refused the procedure and received conservative treatment. Ocular manifestations of the CCF prevailed in all patients (conjunctival injection ‒ in 7 (100 %), diplopia ‒ in 5 (71.4 %), proptosis ‒ in 4 (57.1 %), retro-orbital pain ‒ in 3 (42.8 %), visual impairment in 1 (14.3%). Five (71.4 %) patients complained of headache, 1 (14.3 %) ‒ tinnitus. In 2 (28.6 %) patients spontaneous occlusion was accompanied by an increase in clinical symptoms and their subsequent regression, in 5 (71.4 %) patients there ware a clinical improvement (in 2 (28.6 %) ‒ gradual over several months).Conclusions. Spontaneous occlusion of direct CCF is rare. In order to determine clear predictors regarding the prognosis of this disease and indications for surgical treatment or observation, it is necessary to compare angiographic features, clinical features, and manifestations of the disease.