Caroticocavernous fistula

Case contributed by Dachani Kansan Naider
Diagnosis almost certain


Diplopia and proptosis.

Patient Data

Age: 60 years
Gender: Male
  • contrast opacification identified within the left cavernous sinus and the engorged left orbital vein

  • the entire venous system on the left orbit and left cavernous sinus opacified with contrast on arterial phase CT, which indicates presence of caroticocavernous fistula; this has lead to distension of left ophthalmic and left facial vein

  • given a direct communication between the carotid and cavernous system is not definitely established on CT angiogram, this may reflect a dural shunt between the intracavernous branches of ICA (internal carotid artery) and cavernous sinus

  • no CT evidence of thyroid orbitopathy or orbital mass

Case Discussion

The patient presented with diplopia and proptosis. They had a history of recent insertion of a cardiac prosthesis which was a contraindication to have an MRI head, so the patient proceeded to have a CT head which showed slight enlargement of the left inferior rectus.

Later a CT angiogram of the circle of Willis was performed which showed findings that reflect a possible dural shunt between the intracavernous branches of the ICA and cavernous sinus or known as indirect carotid-cavernous sinus fistula (CCF).

This diagnosis was confirmed with a cerebral digital subtraction angiography (DSA) angiogram by a neurovascular interventionalist and the patient underwent embolization of the CCF with coils and coiling of superior and inferior ophthalmic veins.

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