Factors Influencing Cranial Nerve Palsy in Cavernous Sinus Dural Arteriovenous Fistulas

BACKGROUND AND PURPOSE: Cranial nerve palsy (CNP) is a significant manifestation of cavernous sinus dural arteriovenous fistulas (CSDAVFs), but factors influencing its occurrence, aggravation, and resolution remain unclear. This study aimed to identify clinical and angiographic variables associated with CNP in patients with CSDAVF undergoing endovascular treatment (EVT). MATERIALS AND METHODS: We retrospectively reviewed 196 patients treated for CSDAVF at a tertiary hospital between October 1991 and March 2023. Patient demographics, clinical presentation, imaging findings, treatment specifics, and outcomes were analyzed to identify factors associated with CNP at presentation, aggravation after EVT, and resolution during follow-up. RESULTS: Among the 196 patients (mean age, 59.3 ± 11.6 years; 23.5% men), 73.0% presented with CNP. The proliferative type (OR: 2.82; 95% CI: 1.26–6.29; P = .01) and contralateral feeders (OR: 2.53; 95% CI: 1.17–5.46; P = .02) were significantly associated with initial CNP. Aggravation of CNP occurred in 8.7% of cases, primarily associated with diffuse coil packing (P = .01) and specific coil packing locations in the cavernous sinus (superolateral for third CNP, P =.01; posterolateral for sixth CNP, P < .001). Complete resolution of CNP was achieved in 84% of patients, with hypertension (hazard ratios [HR]: 0.55; 95% CI: 0.35–0.87; P = .01), initial gross extraocular movement limitation (HR: 0.53; 95% CI: 0.35–0.81; P = .003), retreatment (HR: 0.50; 95% CI: 0.28–0.90; P = .02), and orbital pattern (HR: 1.70; 95% CI: 1.03–2.81; P = .04) identified as significant predictors. CONCLUSIONS: Proliferative fistula type and contralateral feeders were associated with initial CNP in CSDAVFs, while coil packing location significantly influenced posttreatment aggravation. Complete CNP resolution was achieved in most patients, though factors such as hypertension, severe initial symptoms, and retreatment negatively affected recovery. These findings highlight key clinical and angiographic variables critical for guiding treatment strategies and predicting outcomes in patients with CSDAVF.