Direct surgery of carotid cavernous fistula and dural arteriovenous malformation of the cavernous sinus

A total of 78 patients with carotid cavernous fistulas or cavernous sinus dural arteriovenous malformations were diagnosed between 1989 and 1996. Obliteration of the fistulous tear with the preservation of the internal carotid artery (ICA) was set as the therapeutic goal. All the patients except one with acute bleeding received endovascular treatment as the first line treatment. Of these 78 patients, 19 could not have their fistulous tears obliterated without sacrifice of the patency of the internal carotid artery. These 19 patients underwent direct surgery to open the cavernous sinus to seal off the fistula. Various methods including suturing of the fistula, sealing the fistula with fascia and acrylate glue, clipping of the fistula, and packing of the cavernous sinus were applied. In 3 patients, due to the complexity of the fistulas and large pseudoaneurysm formation, identification of the fistula was difficult. So, the cavernous segment of the ICAs were trapped and intracranial bypasses from the petrous segment to the supraclinoid segment of the ICAs were performed to reroute the ICAs. There was no mortality and the only morbidity was transient oculomotor palsy which occurred in 7 patients. All these patients had their oculomotor palsy resolved in 1 week to 2 months. Five patients had their ICA or bypass graft thrombosed in follow-up angiography. In the present series, the overall ICA patency rate of the patient received embolization and surgery was 94%, and the obliteration rate of the fistula was 100%.