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case 6  

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ossama yassin mansour
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Joined: 2 years ago
Posts: 10
13/02/2018 5:58 pm  

Clinical Data

This 65 year old patient presented with rapidly progressive left-sided chemosis and proptosis.  No fever. Mildly elevated WBC count.  ESR=28.  There was mild horizontal diplopia on exam, with mild drop in acuity.  No meningeal signs.  She did not appear as sick as we had expected.

Outside institution CT showed enlarged left superior ophthalmic vein, left orbital proptosis, and congestion of the intraorbital fat.  

A diagnosis of carotid cavernous fistula was suspected and patient transferred to us for further workup.

do you agree ? 

MRI upon arrival

with the following findings

confirmed enlarged left superior ophthalmic vein . Post-contrast fat suppressed T1-weighted images show lack of flow  and enhancement of the vessel wall .  

The intraorbital fat is “dirty” .  

 

The cavernous sinus enhances normally (yellow)

DSA was done 

with the following findings

Left ICA injections beautifully demonstrate congestion / hyperemia of the extra-occular muscles (middle image, brown arrows).  The cavernous sinus (yellow) appears late in venous sequence and does not show any drainage — with contrast persisting in the very late venous phase (rightmost image).  The findings imply cavernous sinus thrombosis.  Using arterial phase as a mask in rightmost image allows one to definitively establish the location of the cavernous sinus in relation to the white ICA.

 

 

AP view of the same injection. The EOMs and cavernous sinus are superimposed.

 

 

 

Right ICA injection shows very faint superior ophthalmic vein ( ) and, again, late opacification of a non-draining cavernous sinus (yellow).  The extra-occular muscles (brown) are mildly congested

vertebral injections to conclusively demonstrate lack of cavernous sinus

PATIENTS received anti fugal treatment and UFH and showed dramatic improvement over 48 hours

 


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