PMC4508704_01
Dynamic CTA (preop: axial lateral). A: Dynamic CTA shows dilatation of the left SOV and insufficient intracranial circulation. B: Dynamic CTA shows aggravation of CCF. An increase in the dilatation of the left SOV can be observed in addition to intracranial cortical vein reflux. C: Dilatation of the left SOV and marked retrograde flow in the left intracranial veins can be seen. CCF: carotid-cavernous fistula, CTA: computed tomography angiography, SOV: superior ophthalmic vein.
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F1
Although the symptoms temporarily improved in response to intermittent manual compression of the carotid artery, they became more severe again (Fig. 1).
Preoperative, intraoperative, and postoperative DSA, DA (lateral view). Preoperative (top), intraoperative (middle), and postoperative (bottom). Digital subtraction angiograms (left common carotid arteriogram, lateral view). Preoperative angiogram: A large-volume direct carotid-cavernous fistula (CCF) shunt into the jugular vein is visible in the vicinity of the internal carotid artery at C3-4 in the early arterial phase. Outflow via the shunt into the left superior ophthalmic vein, left sylvian vein, left pterygoid sinus, and venous plexus is visible. More specifically, there was retrograde flow from the left sylvian vein to the cortical veins, and the veins had become dilated and tortuous. In addition, there was also retrograde flow to the right superior ophthalmic vein via the cavernous sinus. Hardly any normal circulation from the arteries into the cranium was observed. Postoperative angiogram: Retrograde flow from posterior to the cavernous sinus into the posterior cranial fossa and retrograde flow into the venous plexus were observed, and although a residual CCF was visible, because the retrograde flow into the right cavernous sinus had resolved and sufficient normal circulation had developed.
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F2
Marked retrograde flow into the intracranial veins was observed, and treatment was performed as described below (Fig. 2).