Imaging diagnosis of dural and direct cavernous carotid fistulae

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 remarkably similar in both dural cavernous sinus fistulae and carotid-cavernous fistulae, but it is possible to differentiate one type from the other. Amongst the available imaging methods (Doppler ultrasonography, computed tomography, magnetic resonance imaging and digital subtraction angiography), angiography is considered the gold standard for the diagnosis and classification of cavernous sinus arteriovenous fistulae. The present essay is aimed at didactically presenting the classification and imaging findings of cavernous sinus arteriovenous fistulae.

Arteriovenous fistula; Cavernous sinus; Ultrasonography; Computed tomography; Magnetic resonance imaging; Angiography

Authorship

Daniela dos Santos Mailing Address: Dra. Daniela dos Santos. Centro de Ciências das Imagens e Física Médica - HCFMRP-USP. Avenida Bandeirantes, 3900, Monte Alegre. Ribeirão Preto, SP, Brazil, 14048-900. E-mail: danisantos2404@gmail.com.

Masters, Physicians Assistants, Unit of Interventional Radiology and Therapeutic Neuroradiology, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.Masters, Physicians Assistants, Unit of Interventional Radiology and Therapeutic Neuroradiology, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.Masters, Physicians Assistants, Unit of Interventional Radiology and Therapeutic Neuroradiology, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.

Lucas Moretti Monsignore

Fellow PhD degree, Physician Assistant, Unit of Interventional Radiology and Therapeutic Neuroradiology, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.Fellow PhD degree, Physician Assistant, Unit of Interventional Radiology and Therapeutic Neuroradiology, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.Fellow PhD degree, Physician Assistant, Unit of Interventional Radiology and Therapeutic Neuroradiology, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.

Guilherme Seizem Nakiri

Antonio Augusto Velasco e Cruz

Full Professor, Teacher at Division of Ophthalmology, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery - Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.Full Professor, Teacher at Division of Ophthalmology, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery - Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.Full Professor, Teacher at Division of Ophthalmology, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery - Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.

Benedicto Oscar Colli

Full Professor, Teacher at Division of Neurosurgery, Department of Surgery and Anatomy - Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.Full Professor, Teacher at Division of Neurosurgery, Department of Surgery and Anatomy - Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.Full Professor, Teacher at Division of Neurosurgery, Department of Surgery and Anatomy - Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.

Daniel Giansante Abud

Professor Responsible for the Unit of Interventional Radiology and Therapeutic Neuroradiology - Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.Professor Responsible for the Unit of Interventional Radiology and Therapeutic Neuroradiology - Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.Professor Responsible for the Unit of Interventional Radiology and Therapeutic Neuroradiology - Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.

Mailing Address: Dra. Daniela dos Santos. Centro de Ciências das Imagens e Física Médica - HCFMRP-USP. Avenida Bandeirantes, 3900, Monte Alegre. Ribeirão Preto, SP, Brazil, 14048-900. E-mail: danisantos2404@gmail.com.

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (10)

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Figure 1
Orbital Doppler ultrasonography. a,b: Female, 73-year-old patient with a diagnosis of DCSF. Exuberant blood flow is seen at color Doppler study (a) and is arterialized at spectral Doppler study (b) in the SOV. c: Female 58- year-old patient with a diagnosis of DCSF. Absence of flow at color Doppler in the SOV, which presents with material with median echogenicity in its interior, compatible with thrombosis.

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Figure 2
Contrast-enhanced computed tomography, arterial phase. Female 73- year-old patient with diagnosis of DCSF. a: Subtle proptosis (dashed line) and extraocular muscle thickening at right (fine arrows). b: Early contrast enhancement at the right SOV, which is slightly ectatic (bold arrow).

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Figure 3
Computed tomography, bone window. a: Female 73-year-old with a diagnosis of DCSF. Subtle proptosis at right (dashed line). b: Male eight-year-old patient with diagnosis of post-traumatic CCF. Subtle proptosis at right (dashed line) and sphenoid bone fracture (bold arrow). The presence of fracture in the skull base suggests a post-traumatic origin in the patient on the image b.

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Figure 4
Encephalon MRI. a,b: Axial, T2-weighted sequence. c: Contrast-enhanced axial T1-weighted sequence. Female 21-year-old patient with diagnosis of DCSF. Extraocular muscle thickening and periorbital fat edema (thin arrows). Proptosis at left (dashed line). Flow void in the SOV (dashed arrow) compatible with increased blood flow. Early contrast enhancement and SOV dilatation (bold arrow).

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Figure 5
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).

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Figure 6
Intracranial vessels MR angiography. a: Lateral view. b: Anteroposterior view. Female 73-year-old patient with a diagnosis of DCSF. Early enhancement of SOV (thin arrow) and facial vein (dashed arrow). Both are ectatic. Subtle early contrast enhancement of the right CS (bold arrow).

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Figure 7
MR angiography of intracranial vessels. a: Lateral view. b: Anteroposterior view. Female 24-year-old patient with diagnosis of spontaneous CCF. Contrast enhancement of the left cavernous sinus which is dilated, with reflux into the right CS (bold arrows). Early contrast enhancement of the SOV (thin arrow) which is dilated.

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Figure 8
Digital subtraction cerebral angiography, arterial phase. a: Lateral view. b: Anteroposterior view. Female 69-year-old patient with a diagnosis of DCSF. Early CS contrast enhancement of the cavernous sinus (bold arrow). Observe the dilatation and early enhancement of the SOV (thin arrow). This CS fistula presented anterior drainage into the SOV and posterior drainage into IPS (dashed arrow). Observe the presence of multiple small supplying meningeal branches (bold arrow)

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Figure 9
Digital subtraction cerebral angiography, arterial phase. a: Right anterior oblique view. b: Lateral view. c: 3D reconstruction. Female 31-year-old patient with a diagnosis of DCSF. Early contrast-enhancement of the cavernous sinus (bold arrows) which drains to the IPS (dashed arrows). One also observes that there is no drainage through the SOV, characterizing a DCSF with only posterior drainage

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Figure 10
Digital subtraction cerebral angiography, arterial phase. a: Left anterior oblique view. b: Lateral view. c: Working view. Male 24-year-old patient with a diagnosis of post-traumatic CCF. Early contrast enhancement of the CS (bold arrows), which is dilated. Early drainage into ectatic SOV (thin arrows). Observe the exact point of laceration of the ICA which communicates with the CS (between the dotted arrows).

Figure 1 Orbital Doppler ultrasonography. a,b: Female, 73-year-old patient with a diagnosis of DCSF. Exuberant blood flow is seen at color Doppler study (a) and is arterialized at spectral Doppler study (b) in the SOV. c: Female 58- year-old patient with a diagnosis of DCSF. Absence of flow at color Doppler in the SOV, which presents with material with median echogenicity in its interior, compatible with thrombosis.

Figure 2 Contrast-enhanced computed tomography, arterial phase. Female 73- year-old patient with diagnosis of DCSF. a: Subtle proptosis (dashed line) and extraocular muscle thickening at right (fine arrows). b: Early contrast enhancement at the right SOV, which is slightly ectatic (bold arrow).

Figure 3 Computed tomography, bone window. a: Female 73-year-old with a diagnosis of DCSF. Subtle proptosis at right (dashed line). b: Male eight-year-old patient with diagnosis of post-traumatic CCF. Subtle proptosis at right (dashed line) and sphenoid bone fracture (bold arrow). The presence of fracture in the skull base suggests a post-traumatic origin in the patient on the image b.

Figure 4 Encephalon MRI. a,b: Axial, T2-weighted sequence. c: Contrast-enhanced axial T1-weighted sequence. Female 21-year-old patient with diagnosis of DCSF. Extraocular muscle thickening and periorbital fat edema (thin arrows). Proptosis at left (dashed line). Flow void in the SOV (dashed arrow) compatible with increased blood flow. Early contrast enhancement and SOV dilatation (bold arrow).

Figure 5 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).

Figure 6 Intracranial vessels MR angiography. a: Lateral view. b: Anteroposterior view. Female 73-year-old patient with a diagnosis of DCSF. Early enhancement of SOV (thin arrow) and facial vein (dashed arrow). Both are ectatic. Subtle early contrast enhancement of the right CS (bold arrow).

Figure 7 MR angiography of intracranial vessels. a: Lateral view. b: Anteroposterior view. Female 24-year-old patient with diagnosis of spontaneous CCF. Contrast enhancement of the left cavernous sinus which is dilated, with reflux into the right CS (bold arrows). Early contrast enhancement of the SOV (thin arrow) which is dilated.

Figure 8 Digital subtraction cerebral angiography, arterial phase. a: Lateral view. b: Anteroposterior view. Female 69-year-old patient with a diagnosis of DCSF. Early CS contrast enhancement of the cavernous sinus (bold arrow). Observe the dilatation and early enhancement of the SOV (thin arrow). This CS fistula presented anterior drainage into the SOV and posterior drainage into IPS (dashed arrow). Observe the presence of multiple small supplying meningeal branches (bold arrow)

Figure 9 Digital subtraction cerebral angiography, arterial phase. a: Right anterior oblique view. b: Lateral view. c: 3D reconstruction. Female 31-year-old patient with a diagnosis of DCSF. Early contrast-enhancement of the cavernous sinus (bold arrows) which drains to the IPS (dashed arrows). One also observes that there is no drainage through the SOV, characterizing a DCSF with only posterior drainage

Figure 10 Digital subtraction cerebral angiography, arterial phase. a: Left anterior oblique view. b: Lateral view. c: Working view. Male 24-year-old patient with a diagnosis of post-traumatic CCF. Early contrast enhancement of the CS (bold arrows), which is dilated. Early drainage into ectatic SOV (thin arrows). Observe the exact point of laceration of the ICA which communicates with the CS (between the dotted arrows).

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