KEM - DEPARTMENTS
Home College Hospital Alumni Contact Departments Feedback
KEM LOGO


Radiology

Case of the Month

Case No. : 66
Month : June
Year : 2004
Contributor : Dr. Reema Sarai

Other Cases

Discussion


CLINICAL PROFILE :


A 10-year-old-girl child presented with complaints of gradually progressive redness and bulging of the left eye since two months and early morning diplopia

Fig. 1
Fig. 1



There were no complaints of diminution of vision nor was there any history of trauma. Examination revealed left eyelid congestion and palpable thrill and audible bruit on the medial canthus of the left eye. Proptosis of the left eye was evident.. On fundoscopy, there was hyperemia.of the disc.

RADIOLOGICAL FINDINGS:

Sonography of the left eye: Prominent left superior ophthalmic vein.

Fig. 2
Fig. 2

MRI Brain: Mild left proptosis with dilated left superior ophthalmic vein and dilated venous channels in the left orbit.

Fig. 3
Fig. 4
Fig. 3
Fig. 4


Four vessel angiogram shows a indirect carotico cavernous fistula which is supplied by the inferolateral and meningohypophyseal branches from the cavernous segment of the left internal carotid artery. It drains anteriorly in to the superior ophthalmic vein and angular vein and posteriorly into the inferior petrosal sinus and jugular vein. Left external carotid angiogram shows a leash of branches from the left middle meningeal artery and left internal maxillary artery. It also drains into the superior ophthalmic vein , inferior petrosal sinus and jugular vein. Left anterior cerebral and middle cerebral artery angiogram shows no abnormality .

Fig. 5
Fig. 6
Fig. 5
Fig.6


Neurointervention Embolisation done via right transfemoral venous access and left femoral arterial access taken for check angiograms .Microcatheter and microwire were navigated via the facial vein into the angular vein via the superior ophthalmic vein into the dilated venous pouch. Embolisation carried out using microplex and hydrocoils

Fig. 7
Fig. 8
Fig. 7
Fig. 8
Fig. 9
Fig. 9

Post embolisation angiogram shows complete obliteration of dural fistula with no opacification of the venous pouch and superior ophthalmic vein .However on the left internal carotid angiogram meningohypophyseal branch is seen to opacify the residual small venous pouch.

Fig. 10
Fig. 11
Fig. 10
Fig. 11
Fig. 12
Fig. 12

The redness and congestion in the patient's eye improved - so did the diplopia.

Fig. 13
Fig. 13


DISCUSSION:

Carotid cavernous fistula is abnormal communication between the carotid arteries and the cavernous sinus.

Etiology:
Direct CCF- congenital ,traumatic (direct and indirect),ruptured intracavernous aneurysm, arterial dissections ,direct surgical trauma and fibromuscular dyplasia.
Indirect CCF- abnormal communication between dural branches of the internal carotid or external carotid artery and cavernous sinus. Causes include pregnancy,sinusitis ,trauma, cavernous sinus thrombosis.
Clinical features-proptosis,chemosis,arterialisation of the scleral veins ,sixth nerve palsy. High flow direct CCFs steal the blood away from intracranial circulation causing ischaemic symptoms . 

Types-A-direct type with high flow. 
B-fistula between meningeal branches of the internal carotid and cavernous sinus. 
C-fistula between meningeal branches of the external carotid and cavernous sinus. 
D-fistula involving meningeal branches of both the internal and external carotids. 

Diagnosis:
Doppler,CT and MRI which show engorgement of the ophthalmic veins and extraocular muscle congestion with proptosis.Angiography is the gold standard    and assesses the exact site of the fistula,its venous drainage and hemodynamic    effect.

Management:
Endovascular intervention in the form of detachable balloons ,coils and liquid embolisation agent (glue).
Home | College | Hospital | Alumni | Contact | Departments | Search | Radiology