Under what circumstances do you treat a low-flow cavernous sinus dural arteriovenous fistula without cortical venous reflux with primary radiosurgery?

The first consideration is whether or not such a lesion requires treatment. Asymptomatic patients with no cortical venous reflux may generally be observed.

If patients do begin to develop symptoms such as diplopia, pulsatile tinnitus, worsening chemosis, proptosis or orbital discomfort, then the second consideration is why radiosurgery is favored over more definitive endovascular treatment.

Typical reasons to consider primary SRS over endovascular occlusion for low-flow carotid-cavernous fistulas would include a lack of a safe venous route to the cavernous sinus or if the patient's medical comorbidities preclude them from undergoing an endovascular intervention. In these cases, rather than attempting more aggressive methods of venous access...