Ruptured cavernous sinus aneurysms causing carotid cavernous fistula: incidence, clinical presentation, treatment, and outcome

Abstract

Background and purpose: In this study, we present our experience with 11 patients with ruptured cavernous sinus aneurysms causing carotid cavernous fistulas (CCFs), to assess the incidence of ruptured cavernous sinus aneurysms causing CCFs and evaluate clinical presentations, treatments, and outcomes.

Patients and methods: During a 10-year period, 10 of 689 (1.5%) endovascular-treated ruptured aneurysms were ruptured cavernous sinus aneurysms causing CCF. One additional patient with a CCF died shortly before treatment of intracranial hemorrhage. All patients had audible pulsatile bruit. Exophthalmus, ocular motor palsy, and decreased vision correlated with venous drainage to the superior ophthalmic veins and intracerebral hemorrhage was associated with major cortical venous drainage in 2 patients.

Results: Two low-flow CCFs closed spontaneously before treatment with resolution of symptoms; the aneurysms were subsequently treated. Eight CCFs were successfully occluded, 5 by coil occlusion of the aneurysm, one by occlusion of the aneurysm with a balloon, and 2 by simultaneous coil occlusion of the aneurysm and internal carotid artery. There were no complications of treatment. Visual acuity returned to normal in all but one patient, and ophthalmoplegia was cured in 6 of 8 patients. In 2 patients, a remaining abducens palsy was surgically corrected.

Conclusion: The incidence of CCF by a ruptured cavernous sinus aneurysm was 1.5%. CCF was the presenting symptom in 24.4% of treated symptomatic cavernous sinus aneurysms. Clinical symptoms correlate with venous drainage. Drainage to cortical veins may lead to intracranial hemorrhage. Endovascular treatment with coils is effective in occluding the fistula.

Fig 1.

Patient 6. Ruptured left cavernous sinus aneurysm in a 70-year-old woman with bilateral exophthalmus, ophthalmoplegia, and decreased vision. A, Frontal view of left internal carotid artery angiogram. High-flow CCF with venous drainage to both cavernous sinuses, superior ophthalmic veins, and inferior petrosal sinuses. There is some cortical venous drainage, but no filling of intracranial vessels. B, Right carotid angiogram demonstrates overflow to the left side and some contribution to the CCF. C, Early arterial phase shows the aneurysm. D, Coiling with balloon protection of the carotid artery. E and F, Closure of the CCF with patency of the internal carotid artery.

Fig 2.

Patient 9. Ruptured right cavernous sinus aneurysm in a 74-year-old woman with bilateral exophthalmus, ophthalmoplegia, and decreased vision. A and B, Frontal (A) and lateral (B) view of right internal carotid artery angiogram. Principal venous drainage to both cavernous sinuses and superior ophthalmic veins. There is some cortical venous drainage. C and D, Arterial (C) and venous (D) phase of left internal carotid angiogram during test occlusion of the right internal carotid artery. Synchronous opacification of cortical veins in both hemispheres indicates tolerance to permanent occlusion. E, Occlusion of the ruptured aneurysm, including the internal carotid artery, with coils.

Fig 3.

Patient 4. CCF in a 61-year-old woman with bilateral exophthalmus, ophthalmoplegia, and decreased vision. A, Lateral view of left internal carotid angiogram shows CCF with principal venous drainage to both cavernous sinuses and superior ophthalmic veins. There is some cortical venous drainage. B, Early arterial phase shows small cavernous aneurysm. C and D, Selective occlusion of the aneurysm with a detachable balloon. E and F, Follow-up angiogram after 4 months shows reopening and enlargement of the aneurysm, subsequently occluded with coils.