Carotid and Transcranial Color-Coded Duplex Sonography in Different Types of Carotid-Cavernous Fistula

Abstract

Background and Purpose-Patients with carotid-cavernous fistula (CCF) may undergo direct or indirect shunting.Ultrasonography has value that is complementary to angiography in the assessment and follow-up of these patients. The aim of this study was to characterize findings provided by carotid duplex sonography (CDS) and transcranial color-coded duplex sonography (TCCD) in patients with different types of CCF. Methods-CDS and TCCD were independently performed by technologists and neurologists. Digital subtraction or MR angiography was interpreted by a neuroradiologist. Ultrasonographic studies were categorized into 4 types: I, direct shunting only; II, direct shunting with a carotid aneurysm; III, indirect shunting only; and IV, mixed (direct and indirect) shunting. In addition to carotid and intracranial flow velocities, volume, and pulsatility, other direct and indirect ultrasound signs of shunting were evaluated. The direct sign of CCF was a mosaic flash detected by TCCD. Alteration of hemodynamic parameters on CDS and demonstration of draining veins with the use of TCCD were considered indirect signs. Results-Fifteen patients (8 men, 7 women) were included in the study. According to angiographic results, patients in ultrasonographic classification types I (nϭ7) and II (nϭ3) corresponded to type A of Barrow's classification. Patients with type III (nϭ8) were Barrow's type C. Type IV (nϭ1) had a combination of Barrow's types A and C. On ultrasound, both direct and indirect signs were seen in types I, II, and IV CCF. The presence of a 2-colored oval mass divided by a zone of separation without turbulence differentiated type I from type II CCF. All patients with type III CCF had indirect signs, and only 1 patient had direct signs on TCCD. Abnormal TCCD findings were most commonly seen through the transorbital window (100%), followed by the transtemporal window (63%) and transforaminal window (40%). Conclusions-If

A case of Delayed Carotid Cavernous Fistula After Facial Gunshot Injury presented as loss of vision with Symptom Resolution After Endovascular Closure Procedure

“…Complete and technically correct cerebellar angiography should provide information regarding internal and external carotid supply, and delineate contralateral side and posterior circulation. [12,13] In instances of traumatic fistula, intervention is required in urgent conditions such as progressive loss of vision, intolerable murmur, and headache, as well as in cases of traumatic aneurysm showing signs of dilatation behind the CS, hemiplegia secondary to intracranial hematoma, impairment of cortical venous drainage, severe epistaxis, or intraocular pressure exceeding 40 mmHg. Dural sinus fistulas may spontaneously regress in 20-50% of cases.…”

Fístula carotídeo-cavernosa

“…The main complications of the procedure include cerebral infarction (0.1-0.5%), adverse effects related to the contrast material, and death (0.1%) (8,10,12,25,32,57) . Initial evaluation is done with Doppler ultrasound (50,58) , computed tomography (5) (CT), and magnetic resonance imaging (4,26) (MRI). Note that normal results in these tests do not exclude the diagnosis (11,12) .…”

“…Ultrasound is useful in differentiating between dural and direct types, but also on follow-up. Increased flow turbulence in the ICA or ECA, inversion and arterialisation of vascular flow are characteristic signs (50,58) . Not every post-traumatic exophthalmos is due to CCF.…”

Carotico-cavernous sinus fistula: Duplex Doppler findings

“…Spontaneous CCF is a dural arterio-venous fistula at the cavernous sinus which is different from traumatic CCF or CCF associated with a ruptured aneurysm at the cavernous internal carotid artery. Cerebral angiography is required in order to differentiate these conditions (1,2) .We report a case of traumatic CCF, in which Doppler sonographic evaluation of the superior ophthalmic vein (SOV) corresponded with that of magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA).…”