Orbital pain, vision loss and orbital murmur, don’t miss the cause

*Only for medical professionals' reference.
Can you tell at a glance? Adult patients have pain in the orbit, loss of vision and orbital murmur
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Look at the image below, what do you consider the patient’s diagnosis? ---Answer dividing line---Are you sure you want to see the answer? ▌ Image analysis A.
MRI low-focus cylindrical axial fat suppression T2 image (a) shows that the outer edge of the left cavernous sinus is curved, the signal of the cavernous sinus is increased, the left extraocular muscles are thickened with edema, and the orbital and orbital Peripheral fat inflammation and exophthalmos
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B.
3D-MRA scan volume reconstruction image (b) shows that the signal/flow space in the left cavernous sinus and left superior ocular vein (going upward in the image) is increased
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▌ Imaging diagnosis of internal carotid artery-cavernous sinus fistula
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▌ Clinical manifestations A.
Internal carotid artery-cavernous sinus connection (CCF) refers to the abnormal communication between the internal carotid artery and the cavernous sinus, which is divided into direct and indirect types
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① Direct CCF causes high-flow arteriovenous shunt between the internal carotid artery and cavernous sinus with relatively acute onset symptoms, including pulsatile exophthalmos, orbital murmur, bulbar conjunctival edema, and occasional intracranial hemorrhage
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②Indirect CCF is a low-flow shunt between the dural branch of the internal or external carotid artery and the cavernous sinus.
It is often spontaneous and has an insidious onset
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B.
MRI scan shows that the outer edge of the cavernous sinus on the affected side is convex (normally straight or sunken)
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The T2 cavernous sinus has an increased flow of empty signals, the ipsilateral superior ocular veins and extraocular muscles are thickened, and the eyeballs are prominent
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C.
Angiography shows early venous filling during the arterial phase (cavernous sinus and superior ocular vein)
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 ▌ Image points A.
CCF (direct or indirect) refers to the abnormal communication between the internal carotid artery and the cavernous sinus
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B.
Direct CCF originates from trauma and manifests as acute onset of pulsatile exophthalmos, orbital murmur, and bulbar conjunctival edema
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C.
Imaging findings include cavernous sinus bulge (with empty signal), thickening of the superior ocular vein and extraocular muscles, and exophthalmos
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D.
CCF endovascular treatment is favored, including gel or coil embolization
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References: [1] Smith A B.
Vascular malformations of the brain: radiologic and pathologic correlation[J].
J Am Osteopath Coll Radiol, 2012, 1(1): 10-22.
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