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Encephalon MRI. a,b: Axial T2-weighted sequence. c: Axial FLAIR sequence. d: Contrast-enhanced T1-weighted sequence. Female 24-year-old patient with a diagnosis of spontaneous CCF. Flow void indicating high flow in the cavernous sinus and in the left SOV, which is ectatic (thin arrows). Also, observe is the increased sinus volume. Proptosis at left (dashed line). Early contrast enhancement and ectasia of both SOVs, predominant at left (bold arrows).
Source publication
Arteriovenous fistulae of the cavernous sinus are rare and difficult to diagnose.
They are classified into dural cavernous sinus fistulae or direct carotid-cavernous
fistulae. Despite the similarity of symptoms between both types, a precise diagnosis
is essential since the treatment is specific for each type of fistula. Imaging
findings are remarka...
Similar publications
Background: Dural fistula to the cavernous sinus (DFCS) is an infrequent pathology that consists in the anomalous communication between the meningeal branches of the internal carotid artery (ICA) and/or the external carotid artery (ECA) and the cavernous sinus. Aim: To perform a systematic review to evaluate clinical and imaging findings in DFCS, a...
Citations
... Direct fistulas are more common than the indirect types but just 0.2% of patients with traumatic brain injuries go on to develop direct fistulas. 4,5 Carotid cavernous fistulas have a varied clinical presentation (ocular symptoms, cranial nerve neuropathies, headache or pulsatile tinnitus) which is dependent on the type, flow dynamics, size, location, route of venous drainage and duration of the fistula. Fistulas may complicate and result in intracranial haemorrhage and ischaemia. ...
... Ultrasonography (US) is a more recent addition to the initial diagnostic workup. 4 Digital subtraction angiography whilst being invasive is necessary for making an accurate anatomical diagnosis and for the planning of further management by identifying the exact location of the breach in the affected artery, the drainage pattern and the possible contributing factors such as thrombosis and aneurysms. At angiography, distal flow and cerebral collateral circulation is also assessed in the event that the ICA needs to be sacrificed in the course of management. ...
... At angiography, distal flow and cerebral collateral circulation is also assessed in the event that the ICA needs to be sacrificed in the course of management. 4,6 Treatment options in CCFs are based on the type of fistula, degree of clinical symptoms and risk of complications. Treatment options in indirect fistulas with low risk of complications include conservative treatment and radiosurgery. ...
Background:
Carotid cavernous fistulas (CCFs) are relatively uncommon and are difficult to diagnose clinically. Radiological imaging plays a significant role in making the diagnosis with recent advances improving the ability of radiologists to diagnose the condition. Despite these developments, digital subtracted angiography (DSA) remains the gold standard in diagnosing CCFs and simultaneously provides the opportunity for intervention.
Objectives:
To determine the imaging findings of patients presenting to Inkosi Albert Luthuli Central Hospital (IALCH) with a CCF and to assess the outcome of endovascular intervention.
Method:
We reviewed the electronic records and archived imaging data of consecutive patients diagnosed with CCF between January 2003 and May 2016 at IALCH, in particular, the imaging findings, intervention and subsequent outcomes.
Results:
Computed tomography (CT) was the most utilised imaging modality prior to patients undergoing DSA. A dilated superior ophthalmic vein (96%) was the most prevalent imaging finding on axial imaging. At DSA, all except two patients had high-flow fistulas. The fistulas predominantly drained anteriorly (69.44%) and a cavernous internal carotid artery aneurysm was identified in eight patients. Occlusion of the fistula was attained in all patients that were compliant with follow-up and underwent intervention (n = 36, 100%), but parent artery sacrifice was required in 10 cases (27.78%).
Conclusion:
A wide range of imaging modalities can be used in the workup of a CCF. CT is currently the most accessible modality in our setting, with limited access to magnetic resonance imaging. On axial imaging, a dilated superior ophthalmic vein is the commonest finding. Classification of a fistula according to flow dynamics and noting the presence of aneurysms or pseudoaneurysms was found to be more practical in comparison to the traditional Barrow's classification. Management outcomes at our institution compare well with available local and international data.
Orbital pathologies can be broadly classified as ocular, extraocular soft-tissue (non-neoplastic and neoplastic), osseous, and traumatic. In this paper, we discuss the key imaging features and differential diagnoses of congenital and developmental lesions (dermoid cyst, dermolipoma), infective and inflammatory pathologies (pre-septal cellulitis, orbital cellulitis, optic neuritis, chalazion, thyroid ophthalmopathy, orbital pseudotumor), and non-neoplastic vascular anomalies (venous malformation, lymphatic malformation, carotid-cavernous fistula), emphasizing the key role of CT and MRI in the imaging work-up. In addition, we highlight the adjunctive role of ocular ultrasound in the diagnosis of dermoid cyst and chalazion, and discuss the primary role of ultrasound in the diagnosis of vascular malformations.
Graphical abstract
Introduction
Indirect carotid-cavernous fistula (CCF) can lead to secondary glaucoma, posing significant treatment challenges. This paper discusses a case where standard embolization failed, and an Ahmed FP7 valved glaucoma tube shunt was crucial for managing the increased intraocular pressure (IOP), highlighting the necessity for individualized surgical approaches.
Case presentation
A 48-year-old female presented in the emergency department with conjunctival hyperemia, proptosis and elevated IOP; initial imaging findings were indicative of orbital inflammatory disease. Further evaluation with cerebral CT angiography revealed a possible CCF. Subsequent angiography confirmed an indirect CCF type D, leading to the patient undergoing endovascular embolization. Final monitoring revealed a subtotal occlusion of the fistula. Although there was some improvement post-procedure, IOP remained elevated despite medication, and subsequent attempts of embolization were unsuccessful. Surgical intervention with a tube shunt was performed, allowing IOP to decreased to a normal range. Optic nerve head optical coherence tomography, standard automated perimetry, and best-corrected visual acuity remained stable during the 33-month follow-up.
Discussion
In managing glaucoma linked to CCF, a multidisciplinary approach is critical. Conservative methods are often adequate, with spontaneous CCF closure observed in a significant percentage. Endovascular embolization is reserved for refractory cases, with embolization showing a higher rate of IOP normalization compared to medication alone. Yet, when fistula closure is challenging or contraindicated, individualized management strategies like glaucoma surgery may be employed.
Conclusions
When fistula closure is not achievable, the Ahmed FP7 valved tube shunt can successfully regulate IOP with minimal complications, providing an effective alternative for refractory cases.
A carotid cavernous fistula (CCF) is a pathological connection between the internal or external carotid artery and the cavernous sinus venous system. Pregnancy has been proposed as a risk factor for spontaneous CCF, but the exact mechanism of risk is unknown. Overall, there are few published reports describing CCF in pregnancy. Study of this risk factor relationship is further complicated by potential ambiguity in diagnosing CCF, which may present as subtle, nonspecific findings on initial workup. We report a case of CCF during pregnancy in which the diagnostic process was notable for misleading, noninvasive, imaging studies.
The sellar, suprasellar, and parasellar space contain a vast array of pathologies, including neoplastic, congenital, vascular, inflammatory, and infectious etiologies. Symptoms, if present, include a combination of headache, eye pain, ophthalmoplegia, visual field deficits, cranial neuropathy, and endocrine manifestations. A special focus is paid to key features on CT and MRI that can help in differentiating different pathologies. While most lesions ultimately require histopathologic evaluation, expert knowledge of skull base anatomy in combination with awareness of key imaging features can be useful in limiting the differential diagnosis and guiding management. Surgical techniques, including endoscopic endonasal and transcranial neurosurgical approaches are described in detail.
Zusammenfassung
Hintergrund
Die Symptomatik und klinischen Befunde bei Patienten mit Carotis-Sinus-cavernosus-Fisteln sind spezifisch, können aber sehr mild ausgeprägt sein. Wir wollen das diagnostische Potenzial der Echographie der Orbita näher beleuchten.
Methoden
In die retrospektive Studie wurden 25 Patienten mit angiographisch gesicherten Fisteln eingeschlossen. Symptome, klinische Untersuchungsergebnisse und die Darstellbarkeit der V. ophthalmica superior in der orbitalen Echographie wurden gegenübergestellt.
Ergebnisse
Die häufigsten Befunde waren Hirnnervenparesen, episklerale Venenstauung oder Exophthalmus. Wurde eine orbitale Ultraschalluntersuchung durchgeführt, konnte eine erweiterte V. ophthalmica superior zu 100 % nachgewiesen werden.
Schlussfolgerung
Die schnell durchführbare Ultraschalluntersuchung liefert wertvolle Informationen zur Differenzialdiagnose eines therapieresistenten roten Auges. In Kombination mit den 3 Kardinalsymptomen episklerale Venenstauung, Exophthalmus und Hirnnervenparese lässt sich die Diagnose einer Carotis-Sinus-cavernosus-Fistel durch die Echographie untermauern. Die weiterführende Bildgebung kann schließlich zielgerichtet veranlasst werden.
Background and purpose:
Carotid-cavernous fistulas are abnormal vascular shunts that can cause various neurologic or orbital symptoms. The purpose of this retrospective study was to evaluate the diagnostic performance of thin-section MR imaging for carotid cavernous fistula in patients with clinically suspected carotid cavernous fistula, and to identify possible imaging predictors of carotid cavernous fistula.
Materials and methods:
A total of 98 patients who were clinically suspected of having carotid cavernous fistula (according to their symptoms and physical examinations) between January 2006 and September 2018 were included in this study. The patients underwent pretreatment thin-section MR imaging and DSA. Thin-section MR imaging consisted of 2D coronal T1- and T2WI with 3-mm thickness and 3D contrast-enhanced T1WI with 0.6 mm thickness. The diagnostic performance of thin-section MR imaging for carotid cavernous fistula was evaluated with the reference standard of DSA. Univariate logistic regression analysis was performed to determine possible imaging predictors of carotid cavernous fistula.
Results:
Among the 98 patients, DSA confirmed 38 as having carotid cavernous fistula. The overall accuracy, sensitivity, and specificity of thin-section MR imaging were 88.8%, 97.4%, and 83.3%, respectively. Possible imaging predictors on thin-section MR imaging included abnormal contour of the cavernous sinus (OR: 21.7), internal signal void of the cavernous sinus (OR: 15.3), prominent venous drainage flow (OR: 54.0), and orbital/periorbital soft tissue swelling (OR: 40.4).
Conclusions:
Thin-section MR imaging provides high diagnostic performance and possible imaging predictors of carotid cavernous fistula in patients with clinically suspected carotid cavernous fistula. Thin-section MR imaging protocols could help decide appropriate management plans for patients with clinically suspected carotid cavernous fistula.
A carotid cavernous fistula (CCF) is an abnormal vascular connection between the carotid arterial system and the cavernous sinus. Traumatic head injury, particularly basilar skull fractures, can result in a type A CCF. Type A CCFs are direct, high-flow shunts between the internal carotid artery and the cavernous sinus. Significant neuro-ophthalmologic sequela can result from such connections, including visual loss. These fistulas are commonly missed on the routine imaging completed following head trauma. If suspected, a cerebral angiography is the gold standard imaging modality, with endovascular coiling being the preferred treatment. Physicians should have a high index of suspicion for CCFs in trauma patients presenting with basilar skull fractures. Prompt recognition and treatment can resolve symptoms and prevent permanent sequela. resumen Una fístula cavernosa carotídea (CCF) es una conexión vascular anormal entre el sistema arterial carotídeo y el seno cavernoso. La lesión traumática de la cabeza, particularmente las fracturas del cráneo basilar, pueden dar como resultado un CCF tipo A. Los CCF tipo A son derivaciones directas de flujo alto entre la arteria carótida interna y el seno cavernoso. Secuelas neuro-oftalmológicas importantes pueden ser el resultado de tales conexiones, incluida la pérdida visual. Estas fístulas se pasan por alto con frecuencia en las imágenes de rutina completadas después de un traumatismo craneal. Si se sospecha, una angiografía cerebral es la modalidad de imagenología estándar, siendo el tratamiento preferido la inserción endovascular. Los médicos deberían tener un alto índice de sospecha de fístulas cavernosas carotídeas en pacientes con trauma que presenten fracturas de cráneo basales. El reconocimiento y el tratamiento oportunos pueden resolver los síntomas y prevenir la secuela permanente. Palabras clave: Fístula cavernosa carotídea, Lesión en la cabeza, Traumatismo cerrado.
