Answer for BIR CoW 15 Jan 2023
DIRECT CAROTICO CAVERNOUS FISTULA
Findings
Left Superior ophthalmic vein appears relatively dilated (3 mm). Increase in thickness of left extra ocular muscles with fat stranding noted in left retro orbital fat causing mild proptosis . Mild convex bulging of left cavernous sinus noted. On dynamic contrast, direct communication noted between Left Cavernous sinus & Cavernous segment of Left Internal carotid artery noted Early filling of dilated Left Superior Ophthalmic Vein noted No filling defect in Left Cavernous sinus
IMPRESSION:
Features suggestive of of Left direct Carotico Cavernous fistula – Barrow Classification Type A
Discussion
Caroticocavernous fistulas represent abnormal communication between the carotid circulation and the cavernous sinus. They can be classified as direct or indirect which are separate conditions with different etiologies. Direct caroticocavernous fistulas are often secondary to trauma and indirect caroticocavernous fistulas have a predilection for the postmenopausal female patient and the onset of symptoms is often insidious. The Barrow classification of caroticocavernous fistulas further characterizes fistulas according to angiographic features: type A: direct connection between the intracavernous internal carotid artery and cavernous sinus type B: dural shunt between intracavernous branches of the internal carotid and cavernous sinus type C: dural shunts between meningeal branches of the external carotid artery and cavernous sinus type D: type B and type C combined CT angiography is the noninvasive imaging modality of choice for evaluation of suspected caroticocavernous fistula. Features include orbital congestion venous engorgement and enhancement dehiscent internal carotid artery (for direct type fistulas): snowman appearance of fistula tract involving the feeding carotid artery and draining venous pouch intracranial hemorrhage from a ruptured cortical vein Catheter-based digital subtraction angiography is the gold standard imaging technique due to its superior spatial and temporal resolution.
REFERENCES:
1.Mauricio Castillo. Neuroradiology Companion. (2006) ISBN: 9780781779494
2. Bithal PK, Rath GP. Interventional Neuroradiology for Carotico-Cavernous Fistula : A Restrospective Analysis and Anaesthetic Implications. J Anaesth Clin Pharmacol 2005; 21(2) : 175-178
3. Halbach V, Hieshima G, Higashida R, Reicher M. Carotid Cavernous Fistulae: Indications for Urgent Treatment. AJR Am J Roentgenol. 1987;149(3):587-93.
4. Pavičić-Astaloš, Jasna, et al. Carotid Cavernous Fistulas in Postmenopausal Women. Acta Clin Croat (2008) 47 (S1): 53-57.
5. Brosnahan D, McFadzean R, Teasdale E. Neuro-Ophthalmic Features of Carotid Cavernous Fistulas and Their Treatment by Endoarterial Balloon Embolisation. J Neurol Neurosurg Psychiatry. 1992;55(7):553-6.
Findings
Left Superior ophthalmic vein appears relatively dilated (3 mm). Increase in thickness of left extra ocular muscles with fat stranding noted in left retro orbital fat causing mild proptosis . Mild convex bulging of left cavernous sinus noted. On dynamic contrast, direct communication noted between Left Cavernous sinus & Cavernous segment of Left Internal carotid artery noted Early filling of dilated Left Superior Ophthalmic Vein noted No filling defect in Left Cavernous sinus
IMPRESSION:
Features suggestive of of Left direct Carotico Cavernous fistula – Barrow Classification Type A
Discussion
Caroticocavernous fistulas represent abnormal communication between the carotid circulation and the cavernous sinus. They can be classified as direct or indirect which are separate conditions with different etiologies. Direct caroticocavernous fistulas are often secondary to trauma and indirect caroticocavernous fistulas have a predilection for the postmenopausal female patient and the onset of symptoms is often insidious. The Barrow classification of caroticocavernous fistulas further characterizes fistulas according to angiographic features: type A: direct connection between the intracavernous internal carotid artery and cavernous sinus type B: dural shunt between intracavernous branches of the internal carotid and cavernous sinus type C: dural shunts between meningeal branches of the external carotid artery and cavernous sinus type D: type B and type C combined CT angiography is the noninvasive imaging modality of choice for evaluation of suspected caroticocavernous fistula. Features include orbital congestion venous engorgement and enhancement dehiscent internal carotid artery (for direct type fistulas): snowman appearance of fistula tract involving the feeding carotid artery and draining venous pouch intracranial hemorrhage from a ruptured cortical vein Catheter-based digital subtraction angiography is the gold standard imaging technique due to its superior spatial and temporal resolution.
REFERENCES:
1.Mauricio Castillo. Neuroradiology Companion. (2006) ISBN: 9780781779494
2. Bithal PK, Rath GP. Interventional Neuroradiology for Carotico-Cavernous Fistula : A Restrospective Analysis and Anaesthetic Implications. J Anaesth Clin Pharmacol 2005; 21(2) : 175-178
3. Halbach V, Hieshima G, Higashida R, Reicher M. Carotid Cavernous Fistulae: Indications for Urgent Treatment. AJR Am J Roentgenol. 1987;149(3):587-93.
4. Pavičić-Astaloš, Jasna, et al. Carotid Cavernous Fistulas in Postmenopausal Women. Acta Clin Croat (2008) 47 (S1): 53-57.
5. Brosnahan D, McFadzean R, Teasdale E. Neuro-Ophthalmic Features of Carotid Cavernous Fistulas and Their Treatment by Endoarterial Balloon Embolisation. J Neurol Neurosurg Psychiatry. 1992;55(7):553-6.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!