clinical presentations, venous drainage patterns, and treatment outcomes in carotid cavernous...
TRANSCRIPT
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Clinical Presentations, Venous Drainage Patterns, and Treatment Outcomes in
Carotid Cavernous Fistula
Yamin Shwe, MD, David Altschul, MD
Santiago Ortega-Gutierrez, MD, MSc
Johanna T. Fifi, MD
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Background • Carotid cavernous fistulas (CCFs) are abnormal communication between
the carotid arteries and cavernous sinus
• Clinical symptoms can be mild to severe based on size, flow rate and shunt location
• Some are reversible with early endovascular treatment
• Indication for treatment – cortical reflux, vision loss, hemorrhage
• Types of CCFs (Barrow’s classification) – type A, B, C, D
Figure - Ellis et al 2012
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Hypotheses
• Venous drainage pattern correlates with clinical symptoms
• Endovascular treatment improves outcome
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Method
• Retrospective review of 46 adults and one infant (5mo-82yrs)
• Clinical presentations - ocular and neurological symptoms from Jan 2004-June 2014
• Complete ophthalmological, neurological exam and DSA prior to treatment and at follow up
• Clinical symptoms and venous drainages were recorded
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Method
• Clinical symptoms – Orbital
• Chemosis, proptosis
– Cavernous • Ptosis, diplopia, ophthalmoplegia, cranial nerves palsies
– Ocular • Increased intraocular pressure, decreased vision, eye
pain
– Cortical • Headache, tinnitus, ataxia
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Method
• Venous drainage – Anterior
• Superior ophthalmic, inferior ophthalmic veins
– Posterior • Superior petrosal, inferior petrosal, sphenoparietal
sinuses
– Inferior • Pterygoid plexus
– Superior • Superficial middle cerebral vein
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Method
• Primary outcome - association between venous drainage pattern and clinical symptoms
• Secondary outcome - clinical symptom improvement at follow up
• Variables were analyzed using χ2 and Fisher exact test
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Signs and symptoms No. of cases
Symptoms
Proptosis 31
Decreased vision 13
Diplopia 12
Headache 12
Tinnitus 10
Eye pain 5
Face pain 3
Ataxia 3
Signs
Chemosis 27
6th nerve palsy 18
3rd nerve palsy 6
Increased ocular pressure 4
Vision loss 4
Results
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Clinical Symptoms vs. Venous Drainage
Anterior Posterior Inferior Superior
Orbital (n=36) (%) (%) (%) (%)
Yes 30 (83) 6 (16) 12 (33) 5 (13)
No 6 (16) 30 (83) 24 (66) 31 (86)
p value 1.00 0.508 0.018* 0.097
Cavernous (n=26)
Yes 21 (80) 8 (30) 14 (53) 8 (30)
No 5 (19) 18 (69) 12 (46) 18 (69)
p value 0.986 0.274 0.501 0.274
Ocular (n=16)
Yes 13 (81) 2 (12) 4 (25) 3 (18)
No 3 (18) 14 (87) 12 (75) 13 (81)
p value 0.999 0.747 0.190 0.997
Cortical (n=16)
Yes 14 (87) 3 (18) 10 (62) 3 (18)
No 2 (12) 13 (81) 6 (37) 13 (81)
p value 0.960 0.997 0.276 0.997
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Venous Drainage vs. Barrow Classification
A B C D P
Superior ophthalmic vein 8 6 10 12 1.000
Inferior ophthalmic vein 1 2 0 0 0.693
Superior petrosal sinus 1 0 0 6 0.264
Inferior petrosal sinus 8 1 2 6 0.037*
Sphenoparietal sinus 0 0 0 2 0.986
Pterygoid plexus 5 0 1 0 0.007*
Superficial middle cerebral vein 3 2 1 3 1.000
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Factors Related to Symptom Recovery at Follow Up
Total (n=47)
Status at follow up P value
Improved No change Worsened
Age (yrs) 57±20 54±20 64±27 81 0.344
Sex Male 14 11 3 0 0.53
Female 33 20 12 1
Venous Drainage Anterior 39 26 12 1 1.000
Posterior 10 9 1 0 0.657
Superior 10 8 1 1 0.226
Inferior 21 15 6 0 0.986
Symptoms Orbital 36 24 11 1 0.999
Cavernous 26 19 6 1 0.703
Ocular 16 9 7 0 0.854
Cortical 16 10 6 0 0.988
Barrow Type A 9 7 2 0 0.682
B 9 7 5 0
C 12 7 5 0
D 17 12 5 0
Management Embolization 40 30 9 1 0.006*
Conservative 7 1 6 0
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0
5
10
15
20
25
30
35
Improved Same Worsened
Embolization
Conservative
No
. p
ati
en
ts
Symptoms at follow up
*
Improved Same Worse
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Discussion
• Our study showed that majority had anterior venous drainage and orbital symptoms but they did not reach statistical significance.
• Venous drainage patterns have been previously described to correlate with clinical symptoms. However, in our small study group, we did not find a consistent pattern of association between the two.
• Nevertheless, patients undergoing endovascular treatment were much more likely to experience symptom improvement at follow up.
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Conclusion
• Clinical symptoms did not reliably predict venous drainage pattern among patients with CCFs in our small study group.
• DSA remains the gold standard when evaluating patients with suspected CCFs.
• Future studies with larger sample sizes are needed to better correlate clinical and angiographic findings and to quantify the effect of treatment based on the time to intervention.
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Acknowledgement
Mentors
David Altschul, MD
Santiago Ortega-Gutierrez, MD, MSc
Johanna T. Fifi, MD
Others
Srinivasan Paramasivam, MD
Alejandro Berenstein, MD
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References
• Ellis, J.A., et al., Carotid-cavernous fistulas. Neurosurg Focus, 2012. 32(5): p. E9
• Larsen D, et al., Treatment of carotid-cavernous sinus fistulae. Interv Neurorad: Strategies and Practical Techniques. Philadelphia: WB Saunders; 1999:215–26
• Barrow, D.L., et al., Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg, 1985. 62(2): p. 248-56.
• Neil, M.R., Carotid-cavernous Fistulas. Walsh and Hoyt’s Clinical Neuro Ophthalmology. 6th ed. Chapter 42. Lippincott Williams&Wilkins. (2005).
• Jung, K.H., et al., Clinical and angiographic factors related to the prognosis of cavernous sinus dural arteriovenous fistula. Neuroradiology, 2011. 53(12): p. 983-92.