Ccf(1)

Dr Arun Gupta Director imaging Deptt

Dr Rakhee Gupta Dr R K Gandhi Dr Vinayak MittalDr Ritesh Mahajan

SPIRAL CT MRI PET-CT

Centre Sector 44-C Chandigarh

CAROTID –CAVERNOUS

FISTULA

DEFINITION BEST DIAGNOSTIC CLUE

Carotid – cavernous fistula ( CCF ), Direct CCF, High velocity CCF .

High flow fistula between the cavernous ICA and cavernous sinus .

Proptosis .Dilated superior

ophthalmic vein and Cavernous sinus .

CAROTID CAVERNOUS FISTULA

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CT FINDINGS MR FINDINGS

Proptosis Orbital edema Enlarged extra ocular

muscles SAH : secondary to reflux

from the cortical veins ( Rupture ) .

Prominent SOV and Cavernous sinus ( may be bilateral) .

Large cavernous sinus with signal voids ( t1w) .

TI ( C) : Enlarged enhancing cavernous

sinus and SOV. Adjacent or diffuse dural

enhancement .MRA :Increased flow related signal in

the CS . Increased signal void in CS : Due

to increased turbulenceFlow in SOV and /or trans-sellar

collaterals .


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USG findings Angiographic findings

Doppler shows reversal of the flow direction in SOV ( posterior to anterior ) .

Very rapid filling of enlarged CS after ICA injection .

Common drainage pathways ( SOV & IOV ..Facial vein) .

Other drainage pathways Superior and inferior petrosal

sinuses ..INTERNAL JUGULAR VEIN

Opposite CS via trans-sellar or basilar plexus .

Vein of Rosenthal ..vein of Galen .Signs of danger : Filling of cortical

veins , pseudoaneurysm , CS varices , thrombosis / obstruction of venous drainage .


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Enlarged SOV Enlarged Extra ocular muscles

CS thrombosis : No fistula on angiography .

Grave’s disease : Signs of hyperthyroidism.

Masses in orbital apex.

Grave’s and inflammatory pseudotumor

Intra-muscular masses ( Metastases) .

D/D

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Pathology Etiology & types

Blood from cavernous ICA to CS ..SOV and petrosal sinuses.

Reflux from cerebral cortical veins occurs when SOV/IOV and petrosal sinuses cannot handle large blood volume …increased risk of SAH .

Skull base fracture commonest . Ruptured cavernous ICA

aneurysm . Younger individuals (prone to

trauma ) average age ( 37 years) . Gender : male .

Individual with collagen vascular disorders

Most tears involve the proximal horizontal or vertical cavernous ICA .

Type A : Direct communication between ICA and cavernous sinus

Type B-D : Indirect communications between the meningeal/dural branches of ICA/ECA and cavernous sinus .

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T1W SEQUENCE T2W SEQUENCE

PROMINENT

SUPERIOR OPTHALMIC VEIN

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PROPTOSIS , PERIORBITAL EDEMA ENLARGED EXTRA OCULAR MUSCLES

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ENLARGED CAVERNOUS SINUS ( Rt ) WITH MULTIPLE FLOW VOIDS IN IT .

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NORMAL CAVERNOUS SINUS AND ICA

CAROTID CAVERNOUS FISTULA TYPES

PRESENTATION TREATMENT

Symptoms develop either spontaneously or days / wks after trauma

Bruit ( 50%) , pulsating exophthalmos , orbital edema / erythema , decrease vision, glaucoma , headache . Severe rapid vision loss ,SAH , Focal deficits ( CN 3-6). ( these findings may be unilateral / bilateral) .

Spontaneous thrombosis rare , progresses if untreated .

ICA / JUGULAR vein compression ..only for small CCF

Embolization (coiling or balloon) : Trans-arterial or transvenous .

Surgery / Gamma knife .


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•FATTAHI TT ETAL : TRAUMATIC CAROTID-CAVERNOUS FISTULA ; PATHOPHYSIOLOGY AND TREATMENT . J CRANIOFACSURG 14 :240-46 ,2003 .•CHUMAN H ETAL ; SPONTANEOUS DIRECT CAROTID- CAVERNOUS FISTULA IN EHLER-DANLOS SYNDROME TYPE 4 : TWO CASE REPORTS AND A REVIEW OF THE LITRETURE . J NEUROOPHTHALMOL 22 :75-81 ,2002 .•DIAGNOSTIC IMAGING BRAIN OSBORN

References

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Ccf(1)

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