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Bilateral spontaneous carotid-cavernous fistulae
  1. Tara Tran1,
  2. Julian Maingard2,
  3. Shalini Amukotuwa2,
  4. Udaya Seneviratne1
  1. 1 Department of Neurology, Monash Medical Centre Clayton, Clayton, Melbourne, Victoria, Australia
  2. 2 Department of Radiology, Monash Medical Centre Clayton, Clayton, Victoria, Australia
  1. Correspondence to Dr Udaya Seneviratne, Department of Neurology, Monash Medical Centre Clayton, Clayton, Melbourne, VIC 3168, Australia; udaya.seneviratne{at}

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A man in his late fifties had right-sided retro-orbital pain and diplopia for 1 month. There was no preceding head trauma. On examination, he had a right abducens palsy with subtle bilateral chemosis and proptosis, but no ocular bruit. The visual acuities were 6/9 on the right and 6/6 on the left whereas pupils, funduscopy, visual fields by confrontation, colour vision and intraocular pressures (right 15 mm Hg, left 20 mm Hg) were normal bilaterally. MR scan of brain (T2-weighted images) showed bilaterally abnormal flow voids in the cavernous sinuses, with enlargement of the cavernous sinuses, right superior ophthalmic vein and left spheno-parietal sinus (figure 1A,B). Follow-up MR imaging with time-of-flight MR cerebral angiography showed abnormal flow signals in these venous structures, indicating a carotid-cavernous fistula (figure 1D). Digital cerebral angiogram confirmed bilateral indirect carotid-cavernous fistulae (barrow type D, see below) with retrograde cortical venous reflux (figure 2), which were successfully treated with endovascular embolisation.

Figure 1

MR scan of brain showing features of a bilateral indirect carotid-cavernous fistula. (A) Coronal T2-weighted image showing enlargement of the cavernous sinuses (arrowheads). Nodular and curvilinear areas of very low signal within the cavernous sinuses (white arrows) represent fistulous channels. The fast blood flow in these …

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  • Contributors TT: literature search, drafting and critical revision of the manuscript. JM: image selection, critical revision of the manuscript. SA: image selection, critical revision of the manuscript. US: study concept and design, literature search, critical revision of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests US has received travel and speaker honoraria from Eisai Australia and LivaNova Australia.

  • Provenance and peer review Not commissioned; externally peer reviewed by Iain McGurgan, Oxford, UK.

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