Spontaneous Dural Carotid-Cavernous Fistula Treated with Microcoil Insertion

Round 1

Reviewer 1 Report

The disease is not rare. Dural carotid cavernous fistulas are spontaneous or idiopathic rather than traumatic. Tretament option is transvenous approach, either transfemoral vein or direct puncture as your exprerience into superior ophthalmic vein.

The shown picture of angiogram is not appropriate, the picture showing only site of the shunt, but not demonstrate ophthalmic vein as you mention.

Author Response

Dear Reviewers,

We are grateful to you for your time and constructive comments on our manuscript. We have implemented the manuscript according to your comments. Changes in the last version of the manuscript are reported as highlighted the changes. Below, we also provide a point-by-point response explaining how we have addressed each of your comments.

 Response to reviewer 1

 

The disease is not rare. Dural carotid cavernous fistulas are spontaneous or idiopathic rather than traumatic. Tretament option is transvenous approach, either transfemoral vein or direct puncture as your exprerience into superior ophthalmic vein.

Thank you for these advices, we have implemented the discussion section, including the main trans venous approaches described in literature to treat carotid cavernous fistula.

The shown picture of angiogram is not appropriate, the picture showing only site of the shunt, but not demonstrate ophthalmic vein as you mention.

We thank you for this comment, we agree with you, and we have changed the description of this picture.

Reviewer 2 Report

The author described the case of treatment of spontaneous dural - cavernous fistula. Author notes,  that that this pathology is rare and there are diagnostic pitfalls. However, is doesn't reflected in the introduction. Even more,  it is unclear why author decided  to present this case. It should be clarified  - first time used method of treatment,  some diagnostic question or other?  Please clarify,  why this pathology is important in clinical practice and what is the novelty of this case. 

The case presented clear, all pictures are clear and correspond to text.  

  Discussion is very short. The author notes,  that "Dural fistulas represent a challenging disease to treat, either because of the difficulty of a prompt diagnosis" (line 81 - 82), but this point is not discussed in the text.  Please comment the difficulty of diagnosis,  note the main signs and symptoms and  provide the frequency of them.  

Line 89 -90: Author notes, that conservative treatment is possible in some cases and use the reference number 6. Please double check the relevance of this reference. 

Line 94 - 96: The author  note,  that most common is embolization with spiral and etc.  However,  the references are very old (1992, 1997 y).  In 2019, the series of 20 cases and literature review was published (AJNR Am J Neuroradiol. 2019 Apr;40(4):699-702. doi: 10.3174/ajnr.A5994). Please include this paper in your manuscript and discuss  it.  Check please for more recent relevant references. 

Author Response

Response to reviewer 2

 

 

The author described the case of treatment of spontaneous dural - cavernous fistula.

Author notes, that that this pathology is rare and there are diagnostic pitfalls.

However, is doesn't reflected in the introduction.

Even more,  it is unclear why author decided  to present this case. It should be clarified  - first time used method of treatment,  some diagnostic question or other?  Please clarify,  why this pathology is important in clinical practice and what is the novelty of this case.

Thank you for these advices; we have implemented the introduction focusing on the clinical applications that emerged from this case report, empathizing the role of a rapid diagnosis and treatment for carotid cavernous fistula.  

The case presented clear, all pictures are clear and correspond to text. 

We thank you for these positive comments.

 

  Discussion is very short. The author notes,  that "Dural fistulas represent a challenging disease to treat, either because of the difficulty of a prompt diagnosis" (line 81 - 82), but this point is not discussed in the text.  Please comment the difficulty of diagnosis,  note the main signs and symptoms and  provide the frequency of them. 

We have included the main clinical characteristics of carotid cavernous fistula and the main differential diagnosis. Furthermore we have emphasized the importance of some clinical features that are important for prompt treatment.

 

Line 89 -90: Author notes, that conservative treatment is possible in some cases and use the reference number 6. Please double check the relevance of this reference.

We have included more recent references regarding the possible conservative treatment. However, in our case considering some clinical features like increased IOP and retinal ischemia was mandatory an endovascular treatment.

 

Line 94 - 96: The author  note,  that most common is embolization with spiral and etc.  However,  the references are very old (1992, 1997 y).  In 2019, the series of 20 cases and literature review was published (AJNR Am J Neuroradiol. 2019 Apr;40(4):699-702. doi: 10.3174/ajnr.A5994). Please include this paper in your manuscript and discuss  it.  Check please for more recent relevant references.

Thank you for this critical advice allowing us to discuss a central point for this disease; we have included and discussed this paper as advised.

Round 2

Reviewer 1 Report

Dural carotid-cavernous fistula (DCCF) is indirect type of CCF which natural history and pathophysiology are different from direct type. DCCF is supplied from meningeal branches ffrom both ECA and ICA, whereas direct type occurs due to a wall defect of the cavernous portion of ICA. Direct type is usually resulted from trauma.

Routinely, the patient should have initial angiogram to determined aggressiveness and planing for treatment access which is mostly by endovascular technique.

Author Response

Dear reviewer, many thanks for your precious advice. 

The manuscript has been revised throughout the text according to your suggestions. 

Reviewer 2 Report

I have no additional comments

Author Response

Many thanks for your precious help