Skip to main content
SpringerLink
Log in

Evaluating the diagnostic performance of non-contrast magnetic resonance angiography sequences in the pre-procedural comprehensive analysis of direct carotid cavernous fistula

  • Interventional Neuroradiology
  • Published:
Neuroradiology Aims and scope Submit manuscript

Abstract

Purpose

Endovascular treatment of direct carotid cavernous fistula (DCCF) requires invasive diagnostic cerebral angiography for diagnosis and planning; however, a less invasive modality like magnetic resonance angiography (MRA) can be useful, especially in high-risk cases. This single-centre study evaluated a newer MR angiography (MRA) sequence, silent MRA and the traditional time of flight (TOF) MRA for pre-procedural treatment planning of DCCF.

Methods

All consecutive DCCF patients who underwent TOF, silent MRA and diagnostic cerebral angiography were included in the study. Angiographic features like rent size, location, draining veins and collateral communicating arteries were analysed and compared between the two MRA sequences, with digital subtraction angiography (DSA) as the gold standard.

Results

Fifteen patients were included in the study. TOF MRA exhibited better sensitivity (76.9% vs 69.2%) in identifying the rent location, correctly pinpointing the location in 93.3% compared to 73.3% with silent MRA. Both MRA sequences showed good agreement with DSA for primary sac and rent size. TOF MRA correctly identified 86.2% of 210 total venous structures compared to 96% by silent MRA. Silent MRA demonstrated higher sensitivity (90% vs 76%) and accuracy (87.69 vs 94.36) in visualisation of involved veins compared to TOF MRA.

Conclusion

Arterial characteristics of DCCF like rent location and rent size were better assessed by TOF MRA. Although both MRA identified venous features, silent MRA correlated better with DSA irrespective of the size and proximity to the site of the fistula. Combining both sequences can evaluate various angioarchitectural features of DCCF useful for therapeutic planning.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

The data collected for the study is available with the author (Dr Dewansh Mishra) and can be requested from the corresponding author.

Abbreviations

DCCF:

Direct carotid cavernous fistula

ICA:

Internal carotid artery

MRA:

Magnetic resonance angiography

TOF:

Time of flight

DSA:

Digital subtraction angiography

SOV:

Superior ophthalmic vein

SWI:

Susceptibility-weighted imaging

CTA:

Computed tomography angiography

FOV:

Field of view

ASL:

Arterial spin labelling

NEX:

Number of excitations

MIP:

Maximum intensity projection

MPR:

Multiplanar reformatted

Acom:

Anterior communicating artery

Pcom:

Posterior communicating arteries

IPS:

Inferior petrosal sinus

SMCV:

Superficial middle cerebral vein

SPS:

Superior petrosal vein

SAR:

Specific absorption ratio

References

  1. Kim D, Choi YJ, Song Y, Chung SR, Baek JH, Lee JH (2020) Thin-section MR imaging for carotid cavernous fistula. AJNR Am J Neuroradiol 41(9):1599–1605

    CAS  PubMed  PubMed Central  Google Scholar 

  2. Chen CC, Chang PC, Shy CG, Chen WS, Hung HC (2005) CT angiography and MR angiography in the evaluation of carotid cavernous sinus fistula prior to embolization: a comparison of techniques. AJNR Am J Neuroradiol 26(9):2349–2356

    PubMed  PubMed Central  Google Scholar 

  3. Kandasamy S, Kannath SK, EnakshyRajana J, Kesavadas C, Thomas B (2023) Non-invasive angiographic analysis of dural carotid cavernous fistula using time-of-flight MR angiography and silent MR angiography: a comparative study. Acta Radiol 64(3):1290–1297

    Article  PubMed  Google Scholar 

  4. Balasubramanian AP, Kannath SK, Rajan JE, Singh G, Kesavadas C, Thomas B (2021) Utility of silent magnetic resonance angiography in the evaluation and characterisation of intracranial dural arteriovenous fistula. Clin Radiol 76(9):712.e1-712.e8. https://doi.org/10.1016/j.crad.2021.05.008

    Article  PubMed  Google Scholar 

  5. Arai N, Akiyama T, Fujiwara K, Koike K, Takahashi S, Horiguchi T et al (2020) Silent MRA: arterial spin labeling magnetic resonant angiography with ultra-short time echo assessing cerebral arteriovenous malformation. Neuroradiology 62(4):455–461

    Article  PubMed  Google Scholar 

  6. Horowitz MB, Purdy PD, Valentine RJ, Morrill K (2000) Remote vascular catastrophes after neurovascular interventional therapy for type 4 Ehlers-Danlos Syndrome. AJNR Am J Neuroradiol 21(5):974–976

    CAS  PubMed  PubMed Central  Google Scholar 

  7. Korkmazer B, Kocak B, Tureci E, Islak C, Kocer N, Kizilkilic O (2013) Endovascular treatment of carotid cavernous sinus fistula: a systematic review. World J Radiol 5(4):143–155. https://doi.org/10.4329/wjr.v5.i4.143

    Article  PubMed  PubMed Central  Google Scholar 

  8. Halbach VV, Higashida RT, Barnwell SL, Dowd CF, Hieshima GB (1991) Transarterial platinum coil embolization of carotid-cavernous fistulas. AJNR Am J Neuroradiol 12(3):429–33

    CAS  PubMed  PubMed Central  Google Scholar 

  9. Kaufmann TJ, Huston J 3rd, Mandrekar JN, Schleck CD, Thielen KR, Kallmes DF (2007) Complications of diagnostic cerebral angiography: evaluation of 19,826 consecutive patients. Radiology 243(3):812–819. https://doi.org/10.1148/radiol.2433060536

    Article  PubMed  Google Scholar 

  10. Adham S, Trystram D, Albuisson J, Domigo V, Legrand A, Jeunemaitre X, Frank M (2018) Pathophysiology of carotid-cavernous fistulas in vascular Ehlers-Danlos syndrome: a retrospective cohort and comprehensive review. Orphanet J Rare Dis 13(1):100. https://doi.org/10.1186/s13023-018-0842-2

    Article  PubMed  PubMed Central  Google Scholar 

  11. Azuma M, Hirai T, Shigematsu Y, Kitajima M, Kai Y, Yano S, Nakamura H, Makino K, Iryo Y, Yamashita Y (2015) Evaluation of intracranial dural arteriovenous fistulas: comparison of unenhanced 3T 3D time-of-flight MR angiography with digital subtraction angiography. Magn Reson Med Sci 14(4):285–293. https://doi.org/10.2463/mrms.2014-0120

    Article  CAS  PubMed  Google Scholar 

  12. Satoh T, Hishikawa T, Hiramatsu M, Sugiu K, Date I (2019) Visualization of aneurysmal neck and dome after coiling with 3D multifusion imaging of silent MRA and FSE-MR cisternography. AJNR Am J Neuroradiol 40(5):802–807. https://doi.org/10.3174/ajnr.A6026

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Slupe AM, Kirsch JR (2018) Effects of anesthesia on cerebral blood flow, metabolism, and neuroprotection. J Cereb Blood Flow Metab 38(12):2192–2208. https://doi.org/10.1177/0271678X18789273

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. van Rooij WJ, Sluzewski M, Beute GN (2006) Ruptured cavernous sinus aneurysms causing carotid cavernous fistula: incidence, clinical presentation, treatment, and outcome. AJNR Am J Neuroradiol 27(1):185–189

    PubMed  PubMed Central  Google Scholar 

  15. Mendez AA, McCarthy DJ, Tonetti DA, Desai SM, Mountz JM, Gardner PA et al (2022) Angiographic predictors of outcomes after balloon test occlusion. SVIN 2(6):e000371

    Article  Google Scholar 

  16. Rojas-Villabona A, Pizzini FB, Solbach T, Sokolska M, Ricciardi G, Lemonis C, DeVita E, Suzuki Y, van Osch MJP, Foroni RI, Longhi M, Montemezzi S, Atkinson D, Kitchen N, Nicolato A, Golay X, Jäger HR (2021) Are dynamic arterial spin-labeling MRA and time-resolved contrast-enhanced MRA suited for confirmation of obliteration following gamma knife radiosurgery of brain arteriovenous malformations? AJNR Am J Neuroradiol 42(4):671–678. https://doi.org/10.3174/ajnr.A6990

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Pollock BE, Kondziolka D, Flickinger JC, Patel AK, Bissonette DJ, Lunsford LD (1996) Magnetic resonance imaging: an accurate method to evaluate arteriovenous malformations after stereotactic radiosurgery. J Neurosurg 85(6):1044–1049. https://doi.org/10.3171/jns.1996.85.6.1044

    Article  CAS  PubMed  Google Scholar 

  18. Mair G (2015) Lack of flow on time-of-flight MR angiography does not always indicate occlusion. BJR Case Rep 2(1):20150187. https://doi.org/10.1259/bjrcr.20150187

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

I would like to thank Dr Jineesh V. for his assistance in statistical analysis of the study.

Funding

The authors did not receive support from any organisation for the submitted work.

Author information

Authors and Affiliations

  1. Imaging Sciences and Interventional Radiology, Sree Chitra Thirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, 695011, India

    Dewansh Mishra, Santhosh Kumar Kannath, Jayadevan ER, Bejoy Thomas & C. Kesavadas

Authors
  1. Dewansh Mishra
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Santhosh Kumar Kannath
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jayadevan ER
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Bejoy Thomas
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. C. Kesavadas
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Concept: Santhosh Kumar Kannath, Dewansh Mishra, Bejoy Thomas. Analysis of results and interpretation: Santhosh Kumar Kannath, Dewansh Mishra, Jayadevan ER, C. Kesavadas. Manuscript preparation: Dewansh Mishra, Santhosh Kumar Kannath. Manuscript revision and final approval: all authors. All authors of this research paper have directly participated in the planning, execution or analysis of this study. All authors of this paper have read and approved the final version submitted.

Corresponding author

Correspondence to Santhosh Kumar Kannath.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethics approval

The study was approved by the institute ethical board.

Informed consent

Institutional ethical committee waived the need for informed consent for this retrospective study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• The contents of this manuscript have not been copyrighted or published previously.

• There are no directly related manuscripts or abstracts, published or unpublished, by any authors of this paper.

• My Institute’s representative is fully aware of this submission.

• Corresponding author takes full responsibility for the data, the analyses and interpretation, and the conduct of the research. The author had full access to all of the data.

• No recognisable images, figures or video is included in this manuscript.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 12 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mishra, D., Kannath, S.K., ER, J. et al. Evaluating the diagnostic performance of non-contrast magnetic resonance angiography sequences in the pre-procedural comprehensive analysis of direct carotid cavernous fistula. Neuroradiology (2024). https://doi.org/10.1007/s00234-024-03342-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00234-024-03342-x

Keywords

Search

Navigation