Several investigations, including magnetic resonance imaging mri, computed tomography ct, and orbital ultrasound are used to noninvasively screen for carotid cavernous fistula ccf, with variable results. Magnetic resonance imaging mri is the best imaging modality for preoperative assessment of patients with anal fistula. Carotid cavernous sinus fistula carotid artery cavernous. Ct scan can depict proptosis, enlargement of the extraocular muscles, dilatation and tortuosity of ophthalmic veins mainly superior ophthalmic vein sov, and enlargement of the ipsilateral cavernous sinus, with bulging of its lateral wall. Mri in perianal fistulae europe pmc article europe pmc. Final diagnosis mri confirmed the final diagnosis to be a carotidcavernous fistula and a right carotid artery aneurysm. The magnetic resonance imaging mri of a patient who has a cavernous dural arteriovenous fistula csdavf demonstrates the connection between the cavernous sinus and the anterior medullary vein amv dashed arrow and subsequently downward to the spinal vein arrow through the bridging vein arrowhead a, b. The fourth type of perianal fistula is the extrasphincteric fistula that composed the 5% of the cases and consists in a direct communication between the perineum and rectum or other viscera with no. When transvenous access is not possible, an alternate approach must be devised. Imaging findings and outcomes in patients with carotid cavernous. Carotidcavernous fistulas ccfs pose an anatomically and physiologically challenging problem for clinicians.
Carotidcavernous fistula an overview sciencedirect topics. The most common method of treatment for these lesions is transvenous endovascular embolization via the inferior petrosal sinus or the facial vein. Arteriovenous fistulae of the cavernous sinus are rare and difficult to diagnose. Carotid cavernous fistula statpearls ncbi bookshelf. Magnetic resonance imaging for primary fistula in ano. Injury to the internal carotid artery causes blood to flow directly to the cavernous sinus at a higher rate than normal, resulting in redness, swelling and pain around the affected eye. This in turn helps make therapy decisions and monitor therapy. Imaging findings are remarkably similar in both dural cavernous sinus fistulae and carotidcavernous fistulae, but it is possible to differentiate one type from the. The results from both cta and mra correlated well with the flow of contrast material observed in a va lateral views in panels h and i. Over the years, numerous classifications have been applied to ccfs. Perianal fistulae commonly occur in middleaged men. Subjects have given their informed consent and the study protocol has been approved. As they are angiographically occult, their diagnosis relies on various mr imaging techniques, which detect different characteristics of the lesions as.
T1weighted brain mri showed left superior ophthalmic vein sov enlargement fig 1 1. Read more about symptoms, diagnosis, treatment, complications, causes and prognosis. The shunting of the blood may produce ocular ischemia 503 and may transmit arterial pulsations. They are thought to be a result of anal gland obstruction, with secondary abscess formation and external rupture of the abscess. The carotidcavernous fistula ccf is an abnormal arteriovenous communication and its drainage pathways may affect the clinic presentation and change treatment approach. The fistula may occur spontaneously but usually occurs following. The cochlea has the approx size of a pea or less and the windows are even tinier. Endovascular treatment strategy for direct carotidcavernous fistulas resulting from rupture of intracavernous carotid aneurysms. Treatment of carotid cavernous fistulas northwestern. If left untreated, cavernomas may lead to intracerebral hemorrhage, seizures, focal neurological deficits, or headaches. The cs extends from the orbital apex and superior orbital fissure anteriorly to the meckel cave and farther posteriorly to the dura and the pores that allow nerves to enter it. Endovascular treatment of carotid cavernous sinus fistula.
Discussion carotid cavernous fistulae represent a direct communication between the arterial flow of the carotid siphon and the venous compartment of the cavernous sinus 1, 2, 3. Classification of cavernous sinus fistulas csfs and dural. A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam. In spite of presenting with similar symptoms, an accurate diagnosis is important, since the treatment is specific for each one of the entities. Caroticocavernous fistulas ccfs occur due to an abnormal communication between the. Magnetic resonance imaging mri angiography indicated the presence of a carotid cavernous fistula with a pseudoaneurysm to the right. Cerebral cavernous malformations are the most common vascular malformations and can be found in many locations in the brain. Any associated cavernous carotid aneurysmvenous varix fig. Investigation of the cavernous sinuses by mri the mri protocol associates coronal thin slices 23 mm on t2 spin echo and t1 spin echo after contrast medium injection covering the cavernous sinuses and orbits, and axial thin slices on t1 spin echo with injection and fat saturation, in some cases completed by axial thin slices on t2 spin echo. Cureus transorbital approach for endovascular occlusion. The levator ani lev ani muscles blend with the puborectalis pr which in turn merges with the circular external sphincter ext.
It can happen suddenly and is often associated with a head injury. To our knowledge, this is the first report of the ct angiographic appearance of carotidcavernous fistulas. Indirect fistulae often occur spontaneously and may be caused by the rupture of. A three plane localiser must be taken in the beginning to localise and plan the sequences. The treatment of a carotid cavernous fistula ccf depends on the severity of the clinical symptoms, its angiographic characteristics, and the risk it presents for intracranial hemorrhage.
Ccf represents an abnormal communication from the carotid artery to the cavernous sinus. Ccfs can be classified based on the hemodynamic properties, the etiology or the anatomy of the shunt. Perilymph fistula page 2 tinnitus talk support forum. Magnetic resonance angiography source images in carotid. Comparison of computed tomographic fistulography and magnetic resonance imaging changhu liang, md1, yongchao lu, md2, bin zhao, md1, yinglin du, ba3, cuiyan wang, md1, wanli jiang, msc4 1shandong medical imaging research institute, shandong university, jinan 250021, china. The volume rendered vr images also help in locating the sov in cases where direct exposure of this vein is. Susceptibilityweighted angiography swan images showed a focal hematoma in the right. This article is from march 2008 and may contain outdated material.
Examination of magnetic resonance angiography mra source images, in addition to the conventional. Imaging diagnosis of dural and direct cavernous carotid fistulae ncbi. The potentially sightrobbing vascular abnormality known as the carotidcavernous sinus fistula ccf can masquerade as conjunctivitis or other common ocular conditions, which diminishes the chance for a speedy diagnosis. A ccf can be due to a direct connection between the cavernous segment of. Brain mri showed a right ccf and vasogenic edema of the right side of the brainstem, right. Imaging lesions of the cavernous sinus american journal. Carotid cavernous fistulas ccfs are an abnormal shunt from the carotid artery to the cavernous sinus. Imaging diagnosis of dural and direct cavernous carotid. It spans from the apex of the orbit to the apex of the petrous temporal bone. Patients with carotico cavernous fistula ccf present with a pulsatile swelling in the eye. Prospective comparison of endosonography, magnetic resonance imaging and surgical findings in anorectal fistula and abscess complicating crohns disease.
Guidelines for the management of cerebral cavernous. A carotidcavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. Carotid cavernous sinus fistula carotid artery cavernous sinus fistula. Mri of dural carotidcavernous fistulas comparisons with. In most instances, endovascular treatment is preferred. Mri and mr angiography findings to differentiate jugular. The cavernous sinuses were symmetric and normal in size, with slightly increased flow voids in the left cavernous sinus. Ruptured cavernous sinus aneurysms causing carotid cavernous fistula. Ct and mri are the preferred noninvasive imaging techniques in diagnostic approach of ccf. Carotidcavernous fistulas ccfs are abnormal communications between the carotid arterial system and the venous cavernous sinus.
Blood is prone to ooze through the leaky junctions between the cells that make up the walls of ccms. Ct scan of the head showed subarachnoid hemorrhage, intraventricular. Highflow direct ccfs usually are traumatic or are caused by rupture of a cavernous aneurysm into the sinus, but a small percentage can be spontaneous. The pertinent anatomy, fistula classification and mri findings will be discussed. The fistula tract between the ica and the cavernous sinus at segment 3 could be visualized by using cta panels ac and mra panels df. The patients chemosis and injection improved with initial treatment using eye drops. Caroticocavernous fistula radiology reference article. Carotid cavernous fistula ccf is an abnormal communication between the cavernous sinus and the carotid arterial system. Caroticocavernous fistulas ccf represent abnormal communication between the. The thing is, you cannot see a perilymph fistula on a mri scan. Initial prospective studies involving mri in the evaluation of fistula inano unrelated to inflammatory bowel disease using eua as the gold standard have shown conflicting results, with.
Magnetic resonance imaging in the management of fistula in ano. Carotidcavernous fistulas provide a free communication between the internal carotid artery and the surrounding cavernous sinus, resulting in high blood flow and high mean pressure in the shunt. The avf of the cs are classified according to anatomy, etiology and hemodynamics, into dural cavernous sinus fistulae dcsf and direct carotidcavernous fistulae ccf. Aortocaval fistula is a severe complication of abdominal aortic aneurysms that may be fatal and requires early diagnosis and prompt treatment.
A 61yearold woman presented with a symptomatic ccf with all but one of the venous access routes to the ccf thrombosed, leaving an engorged superficial middle cerebral vein. We studied a group of patients with csdavf to identify what factors made complete resolution of their clinical symptoms and closure of the davf on magnetic resonance angiography mra by compression therapy possible. The mri protocol at these centers must depict the fistula tract with or without fluid content, and also the pelvic anatomy and its musculature. Four cases in which the diagnosis of carotidcavernous fistula was made by using ct angiography are illustrated. Carotidcavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus.
We evaluated drainage patterns of ccfs by digital subtraction angiography dsa and categorized drainage pathways according to their types and etiology. Examination of magnetic resonance angiography mra source images, in addition to the conventional mra reconstructions, is now also recognised as a useful method of. Carotidcavernous fistulas can be classified into 4 groups according to barrow et al. A carotid cavernous sinus fistula, abbreviated as ccf, is a pathological channel which leads to the communication of the carotid artery and the cavernous sinus in the skull. Carotid cavernous fistula radiology rsna publications online. Multiple venous drainage pathways are illustrated, including the left superior petrosal sinus thin black arrows, left inferior petrosal sinus thick black arrows, right. An aortocaval fistula may be the consequence of penetrating injuries, such as stab or gunshot wounds, or even, exceptionally, of blunt trauma. Rarely though, multiple small communications can develop between the blood vessels around the eye and the. Evaluation of perianal fistulas in patients with crohns.
Check the positioning block in the other two planes. Trauma generally triggers the development of direct carotidcavernous fistulae. Extensive basal ganglia edema caused by a traumatic carotid. Mri helps to accurately demonstrate disease extension and predict prognosis.
Mri for assessment of anal fistula pubmed central pmc. The diagnosis was confirmed by digital subtraction angiography in all four instances. Its transverse diameter is 57 mm, its vertical diameter is 58 mm, and its anteroposterior diameter is 1015 mm. Abstract a carotidcavernous fistula ccf is an abnormal communication between the venous cavernous sinus and the carotid artery. Treatment of carotid cavernous fistulas springerlink. Conventional reconstructed mra did not reveal a fistula. These lesions may be classified based on the following. At times a ccf can be secondary to a spontaneous rupture of an abnormal artery into the vein. An appropriate angle must be given in the axial plane parallel to the line along. We describe a case example with bilateral barrow type b. Hemicranial coughinduced headache as a first symptom of a. The cavernous sinus is located on either side of the pituitary fossa and body of the sphenoid bone between the endosteal and meningeal layers of the dura.
Normal anatomy of the pelvic floor and anal sphincters. External manual carotid compression is a noninvasive method to treat cavernous sinus cs dural arteriovenous fistulae davf. Spontaneous resolution of posttraumatic direct carotid. Immediate defect source analysis revealed a defect at the anteromedial wall of right internal carotid artery ica and associated carotid cavernous sinus fistula. Most often, ccfs are broadly classified as either direct or indirect, on the basis of anatomic features depicted on angiograms. They have traditionally been imaged by conventional fistulograms. The internal sphincter is continuous with the muscularis propria of the rectum, running the length of the anal canal and. The term carotidcavernous fistula ccf refers to an abnormal communication between the internal carotid artery ica or one of its branches or the external carotid artery eca and the cavernous sinus cs.
Sequences the most common sequences are t2weighted images with or without different forms of fat saturation, and t1weighted images before and after gadolinium enhancement and with fat saturation. Venous drainage patterns in carotid cavernous fistulas. Ten patients with dural carotidcavernous fistulas ccfs who presented with ophthalmic. Ccms are also known as cavernomas, cavernous angiomas, or. Posttraumatic carotidcavernous fistulas are due to a tear in the wall of the cavernous carotid. As arterial blood under high pressure enters the cavernous sinus, the normal venous return to the cavernous sinus is impeded and this causes engorgement of the draining veins, manifesting most dramatically as a. Despite the similarity of symptoms between both types, a precise diagnosis is essential since. Ccf can be traumatic or spontaneous, with the traumatic type being more common, representing 75% of all ccfs. They are classified into dural cavernous sinus fistulae or direct carotidcavernous fistulae. Endovascular treatment of carotid cavernous fistulas ccfs via a transvenous approach is standard, but in rare cases this approach is challenging due to absence or thrombosis of the commonly used venous routes. Most of the posttraumatic ccfs are encountered in young male subjects. These findings are typical of a socalled indirect av fistula between the cavernous internal carotid artery and veins within and lateral to the cavernous sinus producing raised retroorbital pressures due to arterialization of the orbital veins causing the globe to be proptosed. Although the book is best suited to those who will be responsible for patient treatment, it is certainly appropriate for any interested individual who.