Thin-Section MR Imaging for Carotid Cavernous Fistula

D. Kim; Y.J. Choi; Y. Song; S.R. Chung; J.H. Baek; J.H. Lee

doi:10.3174/ajnr.A6757

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FIG 1.
Flow diagram of the case selection procedure and case numbers in each subgroup.
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FIG 2.
A CCF case with abnormal contour of the cavernous sinus. Coronal T2-weighted image of a patient with diplopia, confirmed to be left sixth cranial nerve palsy on neurologic examination. Note the abnormal contour bulging of the left cavernous sinus (arrow). An internal signal void was also noted on both T2-weighted (arrow) and T1-weighted imaging (not shown). The patient was confirmed as having a direct CCF on digital subtraction angiography.
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FIG 3.
A CCF case with internal signal void of the cavernous sinuses. Coronal T1-weighted image of a patient with diplopia, confirmed to be right third cranial nerve palsy on neurologic examination. Note the internal signal void in both cavernous sinuses visible on T1-weighted image (arrows). The patient was confirmed to have an indirect CCF on digital subtraction angiography.
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FIG 4.
A CCF case with prominent venous drainage flow in the anterior and lateral venous structures. Axial contrast-enhanced T1-weighted image of a patient with right ocular pain and conjunctival injection. Note the enlarged right superior ophthalmic vein (anterior; arrow) and right sphenoparietal sinus (lateral; arrowhead). The patient was confirmed as having an indirect CCF on digital subtraction angiography.
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FIG 5.
A CCF case with prominent venous drainage flow in the posterior venous structure. Axial contrast-enhanced T1-weighted image of a patient with diplopia, confirmed to be right sixth cranial nerve palsy on neurologic examination. Note the enlarged right inferior petrosal sinus (posterior) with an internal signal void (arrow) indicating increased flow rate. The patient was confirmed as having an indirect CCF on digital subtraction angiography.
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FIG 6.
A CCF case with high signal change and orbital soft tissue thickening. Coronal T2-weighted image of a patient with periorbital swelling, conjunctival injection, ocular pain, and diplopia. Fat stranding and swelling of extraocular muscles (arrow) are noted. Prominent venous drainage flow in the superior ophthalmic vein is also noted (arrowhead). The patient was confirmed as having an indirect CCF on digital subtraction angiography.

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Table 1:

Clinical characteristics of the study patients

	All Patients(n = 98)	CCF Positive Patients (n = 38)	CCF Negative Patients (n = 60)
Sex, n
Male/Female	32/66	11/27	21/39
Age, years
Mean (range)	54.6 (20–85)	66.0 (24–85)	51.4 (20–81)
Symptoms, n (%)
Diplopia	54 (55.1)	20 (52.6)	34 (56.7)
Eyeball pain	27 (27.6)	14 (36.8)	13 (21.7)
Facial pain	2 (2.0)	1 (2.6)	1 (1.7)
Ptosis	30 (30.6)	8 (21.1)	22 (36.7)
Proptosis	14 (14.3)	9 (23.7)	5 (8.3)
Periorbital swelling	19 (19.4)	16 (42.1)	3 (5)
Conjunctival injection	23 (23.5)	16 (42.1)	7 (11.7)
Visual disturbance	18 (18.4)	7 (18.4)	11 (18.3)
Headache	40 (40.8)	14 (36.8)	26 (43.3)
Dizziness	13 (13.3)	5 (13.2)	8 (13.3)
Neurologic signs, n (%)Laterality
Right	30 (30.6)	8 (21.1)	22 (36.7)
Left	22 (22.4)	6 (15.8)	16 (26.7)
3rd cranial neve palsy	26 (26.5)	4 (10.5)	22 (36.7)
4th cranial nerve palsy	5 (5.1)	2 (5.3)	3 (5)
6th cranial nerve palsy	22 (22.4)	8 (21.1)	14 (23.3)
Trauma history, n (%)	5 (5.1)	3 (7.9)	2 (3.3)

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Table 2:

Logistic regression of thin-section MR imaging predictors for CCF

Feature	Total	CCF Cases	Univariable Logistic Regression
Feature	Total	CCF Cases	OR (95% CI)	P Value
Abnormal contour of cavernous sinus	57.1% (56/98)	92.1% (35/38)	21.7 (6.0–78.9)	<.001
Signal void of cavernous sinus	73.5% (72/98)	92.1% (35/38)	15.3 (4.2–55.1)	<.001
Prominent venous drainage flow^{^a}	52.0% (51/98)	94.7% (36/38)	54.0 (11.6–251.7)	<.001
Anterior	36.7% (36/98)	78.9% (30/38)	33.8 (10.7–106.5)	<.001
Lateral	22.4% (22/98)	34.2% (13/38)	3.0 (1.1–7.8)	.030
Posterior	23.5% (23/98)	47.4% (18/38)	9.9 (3.3–30.2)	<.001
Orbital/periorbital soft tissue swelling	39.8% (39/98)	84.2% (32/38)	40.4 (12.5–130.8)	<.001

↵a Prominent venous drainage flow indicates the presence of prominent venous drainage flow in at least 1 of the anterior, lateral, and posterior prominent venous drainage flows.

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Table 3:

Diagnostic performance of each thin-section MR imaging feature and combination of imaging features for CCF^{^a}

	Accuracy	Sensitivity	Specificity	PLR	NLR
Abnormal contour of cavernous sinus	75.5% (65.8–83.6%)	92.1% (78.6–98.3)	65% (51.6–76.9)	2.6 (1.8–3.8)	0.1 (0.0–0.4)
Signal void of cavernous sinus	70.4% (60.7–78.5%)	92.1% (79.2–97.3)	56.7% (44.1–68.4)	2.1 (1.6–2.9)	0.1 (0.0–0.4)
Any prominent venous drainage flow	82.7% (74.0–88.9)	94.7% (82.7–98.5)	75% (62.8–84.2)	3.8 (2.4–5.9)	0.1 (0.0–0.3)
Prominent anterior venous drainage flow	85.7% (77.4–91.3)	79.0% (63.7–88.9)	90% (79.9–95.3)	7.9 (3.6–7.2)	0.2 (0.1–0.4)
Prominent lateral venous drainage flow	65.3% (55.0–74.6)	34.2% (19.6–51.2)	85% (73.4–92.9)	2.3 (1.1–4.8)	0.8 (0.6–1.0)
Prominent posterior venous drainage flow	74.5% (64.7–82.8)	47.4% (31.0–64.2)	91.7% (81.6–97.2)	5.7 (2.3–14.0)	0.6 (0.4–0.8)
Orbital/periorbital soft tissue swelling	86.7% (78.6–92.1)	84.2% (69.6–92.6)	88.3% (77.8–94.2)	7.2 (3.6–14.7)	0.2 (0.1–0.4)
Combination 1 (any prominent venous drainage flow AND internal signal void of cavernous sinus)	91.8% (84.7–95.8)	89.5% (75.9–95.8)	93.3% (84.1–97.4)	13.4 (5.2–34.8)	0.1 (0.0–0.3)
Combination 2 (any prominent venous drainage flow AND orbital/periorbital soft tissue swelling)	89.8% (82.2–94.4)	79.0% (63.7–88.9)	96.7% (88.6–99.1)	23.7 (6.0–93.4)	0.2 (0.1–0.4)
Combination 3 (prominent anterior venous drainage flow OR orbital/periorbital soft tissue swelling)	85.7% (77.4–91.3)	92.1% (79.2–97.3)	81.7% (70.1–89.4)	5.0 (2.9–8.6)	0.1 (0.0–0.3)