Low dose heparin therapy for Dural Cavernous Sinus Fistulas (DCSF)

Purpose. To determine wether neuro-ophthalmological complications of DCSF can be managed with heparin therapy. Methods. Four consecutive patients (1 male, 3 females), aged from 68 to 73 years (mean 70.2 years), were admitted to the study. In all patients selective cerebral angiography showed unilateral DCSF (bilateral in one case) and hemodinamically impaired venous outflow. Mean duration of signs and symptoms was 5.6 months (3 weeks-1 year). Patients were treated with subcutaneous heparin (5000 units tid) for one month. All patients underwent complete neuro-ophthalmological examination at baseline, after three weeks of therapy and one month after heparin withdrawal. At diagnosis intracranial bruit was present in two patients, transient visual loss in one, proptosis in four (mean 6 mm; 4-9 mm), orbital congestion signs in four, increased intraocular pressure despite maximum medical treatment in three (mean: 27.6 mmHg, 25-30 mmHg), sixth nerve palsy in three and retinal venous stasis with optociliary shunt vessels in one. Results. At three week follow-up subjective bruit and transient visual loss episodes disappeared in all patients. Objective signs improved as follows: proptosis (4/4; mean 3.75 mm; 2-5 mm), orbital congestion signs (3/4), intraocular pressure (3/3; mean 18 mmHg; 15-20 mmHg), sixth nerve palsy (1/3). One month after therapy withdrawal visual complications remained stable in two patients; intraocular pressure increased in two, associated in one subject with worsened orbital congestion, proptosis and sixth nerve palsy. Conclusions. Low dose heparin therapy improves neuro-ophthalmological complications of DCSF. These results support a venous thrombotic disease as a major pathogenenetic mechanism of DCSF and related signs and symptoms.