Cavernous dural arteriovenous fistula with cortical venous reflux


Patient presents with features suspicious for cavernous sinus dAVF (also known as caroticocavernous fistula (CCF)). Close inspection identifies the enlarged and asymmetric ipsilateral superior ophthalmic vein, but note should be made of the unusual FLAIR signal of the right frontal lobe adjacent to the Sylvian fissure. This is not typical of small vessel ischemia or old infarction as would be suspected from patient age and intracranial atherosclerosis.  It should prompt consideration of other pathologies - venous hypertension or infarction in this case with ipsilateral cavernous dAVF; tumor in other circumstances.

Close inspection of the DSA confirms retrograde opacification of a cortical vein in the Sylvian fissure, confirming venous "infarction" or hypertension as the etiology, confirmed by resolution of the changes following spontaneous thrombosis of the fistulas on follow-up imaging.