CASE 40: MRI BRAIN

Headache with vision loss

 

 

Large cavernous  sinus with signal voids ( t1w) .

TI ( C) :

Enlarged enhancing cavernous  sinus  and SOV.

Adjacent or diffuse dural enhancement .

MRA :

Increased flow related  signal in the  CS .

Increased signal void  in CS : Due to  increased turbulence

Flow in SOV and /or trans-sellar collaterals 

 

Diagnosis: Carotico Carvernous fistula

 

Discussion:

—Blood from cavernous ICA  to CS ..SOV and petrosal sinuses.

—Reflux from cerebral cortical veins occurs when SOV/IOV and petrosal sinuses  cannot handle large blood volume …increased risk of SAH .

 

Etiology & Types?—Skull base fracture  commonest .

—Ruptured cavernous ICA aneurysm .

—Younger individuals (prone to trauma ) average age ( 37 years) . Gender : male .

—Individual  with collagen vascular disorders

—Most tears  involve the proximal horizontal or vertical cavernous ICA .

Type A : Direct communication between ICA  and cavernous  sinus

Type B-D : Indirect communications  between the meningeal/dural branches of ICA/ECA and cavernous sinus

 

Clinical Findings?—Symptoms develop  either spontaneously  or days / wks after trauma

Bruit ( 50%) , pulsating exophthalmos , orbital edema / erythema , decrease vision, glaucoma , headache . Severe rapid vision loss ,SAH , Focal deficits ( CN 3-6). ( these findings may  be unilateral / bilateral)

 

Treatment?—Spontaneous  thrombosis  rare , progresses if untreated .

—ICA / JUGULAR vein compression  ..only for small CCF

—Embolization (coiling or balloon) : Trans-arterial or transvenous .

—Surgery / Gamma knife

 

Dr Ritesh Mahajan