31 year old male with history of trauma

Images

Doctor's Information

Name :  Hossein
Family :Ghanaati
Affiliation : Department of Radiology, Medical Imaging Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
Academic Degree: Associate professor of Radiology
Email :   This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident :  Ramin Pourghorban

Patient's Information

Gender : Male
Age : 31

Case Section

Interventional Radiology

Clinical Summary

31 year old male with left sided proptosis and chemosis and history of trauma

Imaging Procedures and Findings

Anteroposterior, Lateral and oblique conventional angiographrams (images1-3) demonstrate abnormal communication between the left cavernous internal carotid (C4 segment) artery and adjacent enlarged left cavernous sinus. Immediate drainage is depicted via the very large left superior ophthalmic vein (best shown on image-2), bilateral inferior and superior petrosal sinuses (best shown on image 1 and 3), accompanied by contrast reflux into cortical veins (best shown on image-2).The above-mentioned angiographic findings are consistent with carotid cavernous fistula. Appropriate balloon positioning in the fistulous area with preservation of the ICA is shown on images 4-5. Schematic anatomy of draining veins of skull base is illusterated on image-6.

Discussion

Carotid-cavernous fistulas (CCFs) are acquired lesions involving an abnormal vascular communication between the cavernous portion of the internal carotid artery and the enveloping cavernous sinus. The goal of therapy is to occlude the untoward shunt, preferably with preservation of the involved internal carotid artery. The historically standard method employs a detachable balloon mounted on a microcatheter that is introduced coaxially through a 6-8 French wide lumen guiding catheter positioned proximally within the involved intemal carotid artery. The balloon-mounted microcatheter tip is flow-guided through the lesion from the arterial side by hemodynamic conditions associated with the rapid arteriovenous shunting present. Once positionedon the venous side of the fistula, the balloon is inflated, thereby occluding the shunt, ideally without compromising the internal carotid artery. The balloon is then detached, and the microcatheter is removed. An assortment of easily mounted latex or silicone balloons is available differing in size and shape. In general, they retain their original characteristics after multiple inflations and deflations, a feature that may be necessary in optimally positioning the balloon before detachment. In most cases, the balloon is filled with isotonic contrast to facilitate visualization during the procedure and in the postembolization follow-up. Over the course of several weeks, a latex balloon normally deflates; however, it generally provides an adequate interval of occlusion during which thrombosis of the fistula occurs. Premature deflation or change in the position of the balloon, at the time of the procedure or within 1-2 days, is usually associated with recurrence or exacerbation of symptoms coinciding with an observable change in the disposition of the balloon on plain skull film.

Final Diagnosis

Carotid-cavernous fistula

References

Baum S, Pentecost MJ : Abrams' Angiography Intenrentional Radiology, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006, PP896-900.