Abstract
BackgroundCarotid cavernous fistulas (CCFs) are relatively uncommon and are difficult to diagnose clinically. Radiological imaging plays a significant role in making the diagnosis with recent advances improving the ability of radiologists to diagnose the condition. Despite these developments, digital subtracted angiography (DSA) remains the gold standard in diagnosing CCFs and simultaneously provides the opportunity for intervention.ObjectivesTo determine the imaging findings of patients presenting to Inkosi Albert Luthuli Central Hospital (IALCH) with a CCF and to assess the outcome of endovascular intervention.MethodWe reviewed the electronic records and archived imaging data of consecutive patients diagnosed with CCF between January 2003 and May 2016 at IALCH, in particular, the imaging findings, intervention and subsequent outcomes.ResultsComputed tomography (CT) was the most utilised imaging modality prior to patients undergoing DSA. A dilated superior ophthalmic vein (96%) was the most prevalent imaging finding on axial imaging. At DSA, all except two patients had high-flow fistulas. The fistulas predominantly drained anteriorly (69.44%) and a cavernous internal carotid artery aneurysm was identified in eight patients. Occlusion of the fistula was attained in all patients that were compliant with follow-up and underwent intervention (n = 36, 100%), but parent artery sacrifice was required in 10 cases (27.78%).ConclusionA wide range of imaging modalities can be used in the workup of a CCF. CT is currently the most accessible modality in our setting, with limited access to magnetic resonance imaging. On axial imaging, a dilated superior ophthalmic vein is the commonest finding. Classification of a fistula according to flow dynamics and noting the presence of aneurysms or pseudoaneurysms was found to be more practical in comparison to the traditional Barrow’s classification. Management outcomes at our institution compare well with available local and international data.
Highlights
The cavernous sinuses (CS) are paired dural venous sinuses that form part of a complex network of venous channels into which the superficial venous system of the head drains
Branches of the ICA arising within the CS are the meningohypophyseal artery (MHA), inferolateral trunk (ILT) and capsular artery which in turn give off sub-branches supplying the dural covering of the CS
The medial wall of the CS is supplied by branches of the MHA and capsular arteries whilst the inferior and lateral walls are supplied by the ILT
Summary
The cavernous sinuses (CS) are paired dural venous sinuses that form part of a complex network of venous channels into which the superficial venous system of the head drains It receives venous blood from the superior and inferior ophthalmic veins, Sylvian veins and pterygoid venous plexus and in turn empties into the superior and inferior petrosal sinuses which drain via the internal jugular vein. The ICA’s companion branch, the external carotid artery (ECA), whilst supplying the major structures of the head and neck, supplies parts of the meningeal layers in the cavernous region of the brain via distal sub-branches http://www.sajr.org.za. Radiological imaging plays a significant role in making the diagnosis with recent advances improving the ability of radiologists to diagnose the condition Despite these developments, digital subtracted angiography (DSA) remains the gold standard in diagnosing CCFs and simultaneously provides the opportunity for intervention
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