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There is a high flow, direct (type a) carotid cavernous fistula, filling exclusively from the right internal carotid artery, with flow more rapidly into the posterior part of the cavernous sinus and inferior petrosal sinus, and more slowly into the superior ophthalmic vein. There is some faint retrograde opacification of the sphenoparietal sinus, but no other retrograde cortical venous opacification. Selective external carotid artery injection does not result in opacification of the fistula.
The flow is so rapid, that there is only poor opacification of the internal carotid artery and middle cerebral artery branches on the right from the right side injection-there is some cross flow into the right internal carotid artery Territory from both the posterior circulation, and left carotid.
The opacification of the sinus is so rapid that even on oblique views with rapid frame rate imaging, is difficult to exclude an underlying aneurysm which I suspect is present in the absence of a history of trauma.
There is also an aneurysm identified on the left posterior wall of the internal carotid artery, carotid cave intradural site, 2.5*3mm.
High flow direct right carotid-cavernous fistula, I suspect secondary to a ruptured cavernous internal carotid artery aneurysm, with anterior and posterior drainage, drainage to the contralateral cavernous sinus, and with faint subtle but definite reflux in the sphenoparietal sinus.
Left intra dural small carotid cave aneurysm.