A carotid cavernous fistula is a rare condition and often difficult to diagnose. We herewith present a case of a female patient who presented with minimal proptosis in the right eye and occipital headache. Magnetic resonance imaging showed classical findings like arterialization of ophthalmic veins and tortuous prominent cavernous sinuses on right side. In such situations, magnetic resonance venography (MRV) plays a major role in the diagnosis and may reveal any cerebral thrombosis. We will be discussing the types of CCF and the MRV findings which help in the diagnosis as well as treatment planning

Nagesh, R

Nagraj, Lavanya

Shukla, Anil Kumar

U, Pravin G

VV, Seetha Pramila

English

Atharva Scientific Publications (E-Jounals)

Nagraj et al                            Carotid Cavernous Fistula 
Vol 3 Issue 1 Jan – Mar 2017                                                        Indian J Case Reports / 8 
Case Report 
MRI Evaluation of Carotid Cavernous Fistula – A Case Report 
Lavanya Nagraj, Anil Kumar Shukla, R Nagesh, Seetha Pramila VV, Pravin G U 
From the Department of Radiodiagnosis, Raja Rajeswari Medical College & Hospital, Bangalore, (Karnataka). India 
Correspondence to: Dr. Anil Kumar Shukla – Professor, Radiodiagnosis, Raja Rajeswari Medical College & Hospital, 
Bangalore, Karnataka, India – 560074. E mail: shookla2007@yahoo.co.in. 
Received: 15 Sep 2016    Initial Review: 13 Oct 2016    Accepted:  07 Dec 2016      Published Online: 07 Dec 2016 
ABSTRACT 
A carotid cavernous fistula is a rare condition and often difficult to diagnose. We herewith present a case of a female patient 
who presented with minimal proptosis in the right eye and occipital headache. Magnetic resonance imaging showed classical 
findings like arterialization of ophthalmic veins and tortuous prominent cavernous sinuses on right side. In such situations, 
magnetic resonance venography (MRV) plays a major role in the diagnosis and may reveal any cerebral thrombosis. We will 
be discussing the types of CCF and the MRV findings which help in the diagnosis as well as treatment planning. 
Keywords: magnetic resonance imaging, magnetic resonance venography, ophthalmic vein, cavernous sinus. 
 
arotid cavernous fistula (CCF) is a special type of 
arteriovenous shunt that develops within the 
cavernous sinus. The veins in this condition are 
under high (arterial) pressures. These are almost always 
acquired lesions but the etiology can also be traumatic or 
non-traumatic. Herewith, we present the case of a middle-
aged female patient who came to our hospital with 
complaints of pain and swelling in the right eye of one-
month duration. Magnetic resonance imaging (MRI) 
showed features of dilated and prominent right superior 
ophthalmic vein (with arterialization) and multiple dilated 
cavernous sinus collaterals. MR venogram did not reveal 
any thrombus in the cavernous sinus and a diagnosis of 
CCF was made. 
CASE REPORT 
A 45-year-old female patient presented with complaints of 
pain, proptosis, and swelling of right eye since 1 month 
and associated occipital headache. Symptoms were 
insidious in onset, and gradually progressive in nature. No 
history of similar complaints in the past was present.  
 
The patient was not a known diabetic/hypertensive. 
The local examination revealed swelling of right eye raised 
the local temperature and a bruit. No other significant 
clinical findings were present and systemic examination 
was within normal limits. Laboratory investigation e.g. 
complete blood picture, lipid profile, liver and kidney 
function tests etc were normal. A provisional diagnosis of 
proptosis was made and the patient was referred to the 
department of Radiodiagnosis for an MRI of the orbit to 
look for the cause of proptosis. 
The following MRI sequences were done: Tesla 1 
weighted image (T1WI), Tesla 2 weighted image (T2WI), 
Fluid-attenuated inversion recovery (FLAIR), Time of 
Flight Magnetic Resonance Angiogram (TOF-MRA) and 
Magnetic Resonance Venogram (MRV). MRI (1.5 Tesla 
MR Siemens Avento) evaluation revealed the following 
findings: (1) FLAIR sequence revealed altered signal 
intensity in the intraconal region (Fig. 1a & b). (2) MRA 
showed tortuous and prominent superior ophthalmic vein 
(SOV) and the signal intensity being the same as arterial 
signal intensity suggests arterialization on right side (Fig. 
C 
Nagraj et al                            Carotid Cavernous Fistula 
Vol 3 Issue 1 Jan – Mar 2017                                                        Indian J Case Reports / 9 
1c). (3) 3D-TOF images show multiple tortuous, dilated 
cavernous sinus collaterals (Fig. 2). (4) Maximum 
intensity projections (MIP) images demonstrated all the 
vessels of cerebrum showing meningeal artery forming 
fistulous communication with the cavernous sinus (Fig. 3a 
& b). (5) MRV is done to rule out thrombosis, it revealed 
normal venogram (Fig. 4a, b, & c). Based on these MRI 
findings, a diagnosis of CCF was made. 
       
Figure 1 a, b, & c - FLAIR axial image showing flow void and altered signal intensity in the right intraconal region and 3D-
TOF axial images showing arterialization of dilated superior ophthalmic vein (Arrows). 
 
DISCUSSION 
Valveless venous communication between the cavernous 
sinus and superior ophthalmic vein leads to transmission of 
arterial pressure into the veins of orbit resulting in CCF. 
Bruit and suffusion of the globe, sclera and conjunctiva are 
the hallmarks of CCF. CCF results from abnormal 
communications between the carotid artery (arterial 
system) and the cavernous sinus (venous system). CCFs 
are broadly classified into 3 types [1]. In direct (type A) 
CCF, there is a defect in the wall of internal carotid artery 
(ICA) which communicates directly with the cavernous 
sinus (CS) resulting in a large-volume arteriovenous shunt. 
Indirect or type B CCF is due to communication between 
the branches of ICA/external carotid artery (ECA) and 
cavernous sinus. Third and the most common type is type 
C, where the communication is between meningeal 
branches of the ECA and the cavernous sinus forming the 
fistula [2]. 
Hirabuki et al classified CCF into 4 types depending 
on the level of communication between the branches of 
ICA and CS [3] - 1) Type A - a direct connection between 
the intracavernous ICA and CS, 2) Type B - dural shunt 
between intracavernous branches of the ICA and CS, 3) 
Type C - dural shunts between meningeal branches of the 
ECA and CS, and 4) Type D – features of both type B and 
C.   
 
 
Figure 2 - 3D-TOF axial image showing tortuous dilated 
collaterals along the wall of right cavernous sinus 
(Arrows) 
 
Figure 3 a & b - MRA Images showing arterialization of 
dilated prominent superior ophthalmic vein on the right 
side (Arrows). Meningeal branch of external carotid 
(Curved Arrow) 
Nagraj et al                            Carotid Cavernous Fistula 
Vol 3 Issue 1 Jan – Mar 2017                                                        Indian J Case Reports / 10 
       
Figure 4 a, b & c - MRV in axial, coronal and sagittal images showing normal flow and no thrombosis is seen 
Majority of the time, it is ipsilateral but can be 
contralateral in 10% cases. Less commonly, bilateral 
involvement can be seen due to intercavernous sinus 
connections. Trauma to the head and skull (cranio-
cephalic) is the most common cause of CCF followed by 
spontaneous development due to rupture of an aneurysm 
[4,5]. CCFs are common in men in the age between 20 and 
30 years [6]. Very often, CCF occur secondary to 
cavernous sinus thrombosis with revascularisation, 
pregnancy, surgical procedures in the region, and sinusitis. 
MRI is the investigation of choice in the detection and 
diagnosis of CCF. Features of CCF like dilatation of 
superior ophthalmic vein, proptosis, and extraocular 
muscle thickening can be easily identified on MRI. With 
MR angiography, early contrast enhancement of the 
cavernous sinus and superior ophthalmic vein, and venous 
drainage of the fistula can be identified. Many treatment 
options are available like carotid compression therapy; 
transarterial balloon embolization; detachable coils and 
surgical ligation. 
CONCLUSION 
We would like to reiterate the importance of MR and MR 
venography as the diagnostic modalities of choice as they 
can demonstrate not only the level of communication 
between ICA and CS but also rule out/ confirm the venous 
thrombosis as the possible cause of CCF. 
 
 
 
REFERENCES 
1. Koenigsberg RA. Carotid- cavernous fistula imaging. 
Medscape Oct 28, 2015. 
2. Dos Santos D, Monsiqnore LM, Nakiri GS, Cruz AA, Colli 
BO, Abud DG. Imaging diagnosis of Dural and direct 
cavernous carotid fistulae. Radiol Bras. 2014; 47: 251-
255. 
3. Hirabuki N, Fujita N, Hashimoto T, Fujii K, Miura T, 
Mitomo M, et al. Follow-up MRI in Dural arteriovenous 
malformations involving the cavernous sinus: emphasis 
on detection of venous thrombosis. Neuroradiology. 1992; 
34:423-7.  
4. Millman B, Giddings NA. Traumatic carotid-cavernous 
sinus fistula with delayed epistaxis. Ear Nose Throat J. 
1994; 73:408-11. 
5. Debrun G, Lacour P, Vinuela F, Fox A, Drake CG, Caron 
JP. Treatment of 54 traumatic carotid-cavernous fistulas. J 
Neurosurg. 1981; 55:678-92. 
6. Halbach VV, Hieshima GB, Higashida RT, Reicher M. 
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treatment. AJR Am J Roentgenol. 1987; 149(3):587-93. 
 
How to cite this article: Nagraj L, Shukla AK, Nagesh 
R, Pramila SVV, Pravin GU. MRI evaluation of carotid 
cavernous fistula– a case report. Indian J Case Reports. 
2017; 3(1): 8-10. 
Conflict of interest: None stated, Funding: Nil 


MRI Evaluation of Carotid Cavernous Fistula – A Case Report

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MRI Evaluation of Carotid Cavernous Fistula – A Case Report

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