• Giuseppe Leone, Leonardo Renieri, Alejandro Enriquez-Marulanda, Adam A Dmytriw, Sergio Nappini, Antonio Laiso, Giuseppe Buono, Mariano Marseglia, Adriana Iuliano, Mario Muto, Francesco Briganti, Salvatore Mangiafico, and Nicola Limbucci.
• Department of Neuroradiology, Antonio Cardarelli Azienda Ospedaliera di Rilievo Nazionale, Naples, Italy; Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy. Electronic address: g.leonemd@gmail.com.
• World Neurosurg. 2019 Aug 1; 128: e621-e631.

BackgroundMultiple carotid cavernous fistula (CCF) classifications have been proposed. However, they lacked predictive factors for the clinical presentation, natural history, and hemorrhagic risk. Our aim was to externally validate a new classification according to venous drainage (i.e., the Thomas classification [TC]) to assess its relationship with symptoms, endovascular treatment, and outcomes.MethodsWe performed a multicenter retrospective review of CCFs at 2 major academic institutions. The CCFs were classified using the Barrow classification (BC) and TC systems.ResultsThe data from 94 patients with a diagnosis of CCF were collected during a study period 23 years, 4 months. Of these 94 patients, 89 had undergone CCF treatment and 5 had experienced spontaneous occlusion. Complete occlusion was achieved in 89.9% of the treated patients. Complications occurred in 5.3% of the patients, including permanent deficits in 2.1%. TC type 4 was associated with cortical symptoms compared with type 2 (P = 0.003) and type 3 (P < 0.001). The BC was not able to detect significant differences among the symptom types. Significant differences were found using the TC for the transarterial-only, transvenous anterior-only, and transvenous posterior-only approaches (P < 0.001, P = 0.03, and P = 0.001, respectively). The transvenous posterior and transvenous anterior approach were significantly associated with type 2 and 3 TC, respectively. Excluding direct CCFs, the BC was not related to the treatment approach. No significant differences in the outcomes were found. However, a trend toward a lower occlusion rate for TC type 4 compared with type 3 was observed.ConclusionThe TC provided useful information regarding the fistula anatomy and venous hemodynamics, which correlated with the clinical symptoms and treatment strategy.Copyright © 2019 Elsevier Inc. All rights reserved.

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