Ophthalmoplegia consistent with a pulse is one of the symptoms of direct carotid cavernous sinus fistula. A few direct carotid cavernous fistulas are spontaneous and result from rupture of an aneurysm in the cavernous sinus segment of the internal carotid artery, which can be indistinguishable from traumatic on angiography. How can we effectively prevent eye flutter in line with pulse? I. Treatment The main goals of carotid cavernous sinus fistula treatment are to protect vision, eliminate murmurs, retract the proptosis and prevent cerebral ischemia. The principle of treatment is to close the fistula while maintaining patency of the internal carotid artery. Treatment depends on the flow rate and flow through the fistula, the arterial supply and the venous drainage route. A small number of patients with mild symptoms and slow progression may be considered for conservative therapy and cervical compression therapy, but the majority of direct carotid cavernous sinus fistulas rarely have a chance of self-healing, especially those with massive rhinorrhea, acute visual loss or blindness, intracranial hematoma or subarachnoid hemorrhage, and severe cerebral ischemia, which should be treated as an emergency. At present, endovascular intervention is preferred for carotid cavernous sinus fistula, and direct surgery can be considered if intervention is difficult or if the internal carotid artery has been previously ligated. If the carotid artery has been ligated and occluded or the internal carotid artery is tortuous and narrow, it is difficult to cannulate or the fistula is too small for the balloon to pass through, the transcavernous sinus or supraocular vein approach can also be chosen. â‘ Detachable balloon: detachable balloon embolization method is simple, less traumatic and less complications. The operator delivers the balloon catheter into the fistula opening under fluoroscopy and fills the balloon with isotonic contrast; then injects the contrast agent through the guide tube. If the fistula is occluded and the internal carotid artery is patent, the balloon can be released; if one balloon does not occlude the fistula, several balloons can be placed. Ideally, the balloon should be located in the cavernous sinus outside the lumen of the internal carotid artery, so that the cavernous sinus is no longer visible and the internal carotid artery is flowing smoothly. However, this method may encounter some difficulties, such as the balloon may block both the fistula and the internal carotid artery; premature leakage of the contrast medium in the balloon makes the balloon smaller and displaced, resulting in the reopening of the fistula; fracture of the skull base, the fragment of bone protruding into the sinus pierces the balloon causing the reopening of the fistula; the fistula is too small for the catheter and balloon to be delivered. In the last resort, the internal carotid artery can only be occluded, but an occlusion test of the internal carotid artery must be performed beforehand to understand the conditions of the collateral circulation and the patient’s tolerance. â‘¡Microspring coil: The microspring coil is made of platinum or tungsten wire with a diameter of 0.33-0.36 mm and can be passed through the Magic3F/2F microcatheter to enter smaller fistulae where the balloon cannot easily pass. Once the tip of the microcatheter is inside the cavernous sinus, the microspring coil is fed in and the mechanical embolic effect of the coil itself and the nylon fibers it carries induce thrombus formation to occlude the fistula. This method rapidly promotes thrombus formation in the cavernous sinus, the fistula is closed by the thrombus, and the internal carotid artery remains patent, which is the goal of treatment. This method can be used not only in the arterial route but also in the venous route for embolization, which has a wide application prospect. Liquid embolic agents: Liquid embolic agents such as IBCA (cyanoacrylic acid-isobutyl ester), HEMA (2-hydroxyethyl methacrylate), etc. are rarely used alone due to the high operational difficulty and the tendency to cause cerebral embolism, and are only used as a supplement to microspring coil embolization when necessary. Embolization of internal carotid artery with wires, also known as “kite flying method”. The embolus is injected into the internal carotid artery through a small incision in the carotid artery. The embolus floats with the blood flow to the fistula and then blocks the fistula opening. Hemostatic sponges and polyurethane can also be used as plugs. However, this method is very blind and is rarely used nowadays. 2.Surgical treatment Repair the internal carotid artery breach of the cavernous sinus under direct vision. parkinson surgery, through the lateral wall of the cavernous sinus, the lower edge of the talocrural nerve, the upper edge of the ophthalmic branch of the trigeminal nerve and the Parkinson triangle formed by the line from the dorsal saddle to the slope, enter the cavernous sinus, find the fistula along the internal carotid artery in the sinus and clip or suture it. dolence surgery, using a wing point incision, open the rock bone carotid canal, temporarily blocking the internal carotid artery, exposing the internal carotid artery in the cavernous sinus segment, and performing repair or ligation. The Whitehorse procedure, in which the fistula is repaired through the medial triangle between the superior wall of the cavernous sinus, the anterolateral margin of the posterior bed process, the anterior margin of the entrance to the arteriolar nerve, and the point where the internal carotid artery crosses the dura mater. The above procedures, which are more traumatic and risky, do not have a high success rate and are difficult to be applied widely, and are only suitable for attempts after the failure of various methods. Because of the negative charge on the surface of blood cells and the positive charge on the surface of metal wires such as copper, the insertion of copper wires into the cavernous sinus can close the fistula by causing the organic components of the blood to coagulate around the copper wire to form a clot and achieve the purpose of treatment. The copper wire can be inserted through the superior ophthalmic vein, through the pterygo-parietal sinus, the middle cerebral vein or directly through the wall of the cavernous sinus after craniotomy. After insertion of the copper wire, an electric current (0.2 to 0.8 mA DC) is applied to accelerate the formation of intra-sinus thrombus. Once the murmur disappears, the fistula is nearly occluded and the operation can be completed. This method is simple and has a high patency rate of the internal carotid artery, but the disadvantage is that the fistula may be incompletely occluded. Combined ligation of the extracranial and supratentorial segments of the internal carotid artery with intra-arterial muscular tamponade eventually results in complete occlusion of the fistula as the blood flow in this segment disappears and thrombus forms. This method is simple and can also achieve the goal of murmur disappearance and improvement of ocular symptoms, but because of the sacrifice of the internal carotid artery, patients with poor cerebral collateral circulation will experience cerebral ischemia and even disability; at the same time, because the ligation of the internal carotid artery blocks the arterial access for later endovascular treatment, it is only applied when other methods are ineffective. Prognosis With the improvement of interventional embolization technology, the treatment effect of direct carotid cavernous sinus fistula has been greatly improved, and the complication rate has been greatly reduced.