Presentation
Family history subarachnoid hemorrhage. Screening.
Patient Data
Unusual pattern of apparently arterialized flow within the left cavernous sinus, extending posteriorly as far as the transverse sinus and internal jugular vein on the left.
The left-sided location and extent of high signal over multiple slabs is also typical for incidental jugular reflux.
A carotid-cavernous fistula or dural arteriovenous fistula can have a similar appearance, however, the lack of superior ophthalmic vein dilatation would be unusual.
Despite the venous anatomy, and earlier MRI, a DAVF could not be identified. As the patient is asymptomatic, and no definite abnormality found on the DSA, if subsequent non invasive follow up is planned, suggest inclusion of pre and post contrast imaging, and contrast enhanced MRV.
Early flow is again shown in the left cavernous sinus, extending to the transverse sinus, stable compared with the prior MRI. Time-resolved angiography demonstrates retrograde flow up the left internal jugular reflux and across to the right side accounting for the MRA TOF findings.
Case Discussion
Reflux of the left IJV is a recognized cause of abnormal appearing MRA 1.
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