# Spontaneous Dural Carotid-Caverous Fistula Treated with Microcoil Insertion
## 3 Discussion  
Dural fistulas represent a challenging disease to treat, either because of the difficulty of a prompt diagnosis or because of the difficulty of the intervention dictated by the size and tortuosity of the vessels and, not least, the difficulty of coordinating the multidisciplinary team [1,2].  
All these problems must be promptly overcome in order to have integrative restitution of the whole visual apparatus.  
Ophthalmologists are often the first doctors to come into contact with patients with carotid-cavemous fistula, and they should recognize and indicate the necessary examinations in a timely manner. The typical clinical manifestations are: unilateral protosis, the tumescence of the eyelid, conjunctival chemosis, caput medusae, pulsation of the eyeball (always observed in direct fistula), increased IOP, and diplopia. Furthermore, these clinical features should be differentiated into endocrine orbitopathy, orbital-cellulitis, posterior scleritis, thrombosis of the sinus cavernous, and malignancies.  
In some cases, when the diagnosis is delayed, the visual functionality could be irreparably damaged, with severe ocular and neurological complications [1,2].  
A conservative approach could be indicated for patients with few clinical signs, in particular for indirect fistula, because of a good chance of spontaneous occlusion of the fistula; however, it is also necessary to ensure regular observation of psycho-physical functions, IOP, and the ocular fundus [4, 5, 6, 7].  
In our case, the increased IOP and the ischemic retinal features justified the urgency of treatment aimed at prompt fistula occlusion.  
Currently, the most common treatment is endovascular embolization using means of spirals, detachable flasks, and, as a last resort given the side effects (such as diffuse thrombosis and post-operative inflammatory reaction), the use of a slcerotic substance [8, 9, 10].  
Transvenous via through the inferior petrosal sinus is the most common approach; however, when this access is absent for anatomical variations or thrombosis, direct access to the superior ophthalmic vein represents an alternative technique. [PERSON] et al., in a recent study, reported successful results of imaging-guided percutaneous superior ophthalmic vein access in 20 patients with carotid-cavemous fistula treatment [10].  
In conclusion, our case demonstrated that a prompt diagnosis and multidisciplinary management are essential for clinical resolution and to preserve the visual function of the patient.  
Conceptualization, P.F.F. and L.D.S.; methodology, G.W.O.; investigation, P.F.F. and L.D.S.; resources, A.M.; data curation, L.I.; writing--original draft preparation, G.W.O.; writing--review and editing, G.W.O. and A.M.; supervision, A.M. and P.A. project administration, P.A.; funding acquisition, A.M. All authors have read and agreed to the published version of the manuscript.  
The authors did not receive any financial support from any public or private sources. The authors have no financial or proprietary interest in a product, method, or material described.  
Figure 8: Resolution of the dilatation of the episcleral vessels, exophthalmos, and ophthalmoplegia.