Gamma Knife Radiosurgery for Carotid - Cavernous Fistula in Elderly Patients

Brigitte Gatterbauer1, Harald Standhardt2, Adolf Ertl2, Josa Frischer2, Engelbert Knosp2, Klaus Kitz2

1Vienna, Austria 2Department of Neurosurgery, Medical University Vienna, Währinger Gürtel 8-20,

Keywords: arteriovenous fistula, gamma knife, dural arteriovenous fistula, outcome, radiosurgery

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     In the treatment of carotid cavernous fistula (CCF) a therapeutic approach is warranted in patients presenting with elevated intraocular pressure, visual deterioration, progressive or severe cranial nerve palsy and exophthalmia. The most common therapeutic approach is endovascular embolisation. However, neurologic complications of cerebral angiography and embolisation are reported and seem to be significantly more common in elderly patients. 
     The study aim is to present GKN as treatment possibility for CCF in elderly patients, leading to a rapid improvement of symptoms.
     11 elderly patients underwent 13 GKN procedures. The mean age of patients was 67.3 years (6.9 years SD).
     In a retrospective study we analysed all patients presenting with CCF and treated with Gamma Knife radiosurgery (GKN) in our department between 2000 and 2009.  Detailed clinical chart review was performed for all patients. The current clinical status of the patients was assessed via a neurological examination, resulting in a mean follow up time of 2.9 years (2.6 years SD). The patient’s outcome was rated according to their residual symptoms. Descriptive statistical analysis included mean values and standard deviation (SD).
     All patients presented with a broad spectrum of symptoms. In detail ciliary injection (n=8), exophthalmia (n=7), chemosis (n=8), diplopia (n=5), headache (n=8), visual symptoms (n=6), tinnitus (n=2), elevated intraocular pressure (n=4). Five patients underwent endovascular embolisation before GKN. The irradiated mean volume was 0.5ccm (0.3ccm SD). The mean prescription radiation dose was 17 Gy (0.8 Gy SD) and the central dose 35.5 Gy (3.2 Gy SD). In two patients a second GKN treatment was necessary. At the time of follow-up, clinical symptoms were improved substantially in 27.3% and disappeared completely in 72.7% of patients. Therefore, angiography for demonstration of occlusion was relinquished to avoid the higher risk of complications in elderly patients. Residual symptoms were minor and included ciliary injection (n=2) and mild exophthalmia (n=1).
     This was a retrospective study.
     GKN is an effective treatment for CCF in elderly patients with a low risk of complications. Intraocular pressure normalises rapidly.
     Improvement of clinical symptoms seems to be a sufficient outcome measure in patients with CCF, thus rendering post-radiosurgery angiography an unnecessary risk.


Project Roles:

B. Gatterbauer (), H. Standhardt (), A. Ertl (), J. Frischer (), E. Knosp (), K. Kitz ()