{"id":2347,"date":"2009-11-23T11:06:14","date_gmt":"2009-11-23T18:06:14","guid":{"rendered":"http:\/\/www.ajnrblog.org\/?p=2347"},"modified":"2011-02-04T15:28:37","modified_gmt":"2011-02-04T22:28:37","slug":"aunt-mickey-they-look-the-same-until-you-undress-them-carotid-cavernous-fistula-or-something-else","status":"publish","type":"post","link":"https:\/\/www.ajnrblog.org\/2009\/11\/23\/aunt-mickey-they-look-the-same-until-you-undress-them-carotid-cavernous-fistula-or-something-else\/","title":{"rendered":"Aunt Mickey (They Look the Same until You Undress Them). Carotid-Cavernous Fistula or Something Else?"},"content":{"rendered":"<p>A middle age woman presented with left progressive proptosis.\u00a0 A contrast enhanced CT was done and showed enlargement of the left superior ophthalmic vein on the axial plane (see below).\u00a0 A coronal image confirmed this abnormality and demonstrated that the extraocular muscles and retro-orbital fat had a normal appearance.<\/p>\n<p><a href=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/26489078_2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-2341\" title=\"26489078_2\" src=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/26489078_2-150x150.jpg\" alt=\"26489078_2\" width=\"191\" height=\"191\" \/><\/a><\/p>\n<p><a href=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/126391577.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-2342\" title=\"126391577\" src=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/126391577-150x150.jpg\" alt=\"126391577\" width=\"191\" height=\"191\" \/><\/a><\/p>\n<p>Physical examination showed no chemosis, vision loss or cranial nerve palsies.\u00a0 Because of this the patient was brought back for repeat contrast enhanced CT of the orbits with Valsalva maneuver.\u00a0 This study showed mild additional enlargement of the already prominent left superior ophthalmic vein and also of the right sided one (see below).\u00a0 The combination of imaging and clinical findings was thought to be most compatible with orbital varices.\u00a0 The patient opted for conservative management.<\/p>\n<p><a href=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/126391330.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-2345\" title=\"126391330\" src=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/126391330-150x150.jpg\" alt=\"126391330\" width=\"190\" height=\"190\" \/><\/a><\/p>\n<p><a href=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/1263913901.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-2346\" title=\"126391390\" src=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/1263913901-150x150.jpg\" alt=\"126391390\" width=\"191\" height=\"191\" \/><\/a><\/p>\n<p>Orbital varices are hamartomas composed of slow flow, low pressure and thinned walled and distensible blood vessels.\u00a0 As they communicate with the rest of the circulation, they enlarge with Valsava, bending or prone position, and coughing and straining.\u00a0 They produce proptosis which may be painful and because they may bleed, their symptoms may become acutely exacerbated. \u00a0They may also erode adjacent bone.\u00a0 Treatment is very difficult and is reserved for those with repeated hemorrhages, thrombosis, optic nerve compression and disfigurement.\u00a0 Orbital vascular processes included in the differential diagnosis are carotid cavernous fistulas of both types and less likely, venous thrombosis.<\/p>\n<p>In CC fistulas, the ipsilateral cavernous sinus may be enlarged particularly in the direct ones (see below).\u00a0 Extra-ocular muscles may also be large and the retro-ocular fat may have a \u201cdirty\u201d appearance.\u00a0 In most patients with direct CCFs, chemosis, decreased vision and cranial nerve palsies are present.\u00a0 Acute thrombosis of the superior ophthalmic vein may present with symptoms that are similar to those of a direct CCF.\u00a0 Indirect CCFs may have less acute symptoms and be clinically similar to varices.\u00a0 The diagnosis is confirmed with catheter angiography as shown here.<\/p>\n<p><a href=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/123690002.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-2348\" title=\"123690002\" src=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/123690002-150x150.jpg\" alt=\"123690002\" width=\"129\" height=\"129\" \/><\/a><a href=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/123690038.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-2349\" title=\"123690038\" src=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/123690038-150x150.jpg\" alt=\"123690038\" width=\"128\" height=\"128\" \/><\/a><a href=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/118998114.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-2350\" title=\"118998114\" src=\"http:\/\/www.ajnrblog.org\/wp-content\/uploads\/118998114-150x150.jpg\" alt=\"118998114\" width=\"124\" height=\"124\" \/><\/a><\/p>\n<p>Suggested readings:<\/p>\n<p>YO Arat, ME Mawad, M Boniuk. <strong>Orbital Venous Malformations: Current Multidisciplinary Treatment Approach.<\/strong> Arch Ophthalmol\u00a02004; 122: 1151 &#8211; 1158<\/p>\n<p>N Islam, K Mireskandari, GE Rose. <strong>Orbital varices and orbital wall defects.<\/strong> Br J Ophthalmol\u00a02004; 88: 1092 &#8211; 1093<\/p>\n<p>A Weill, C Cognard, L Castaings, G Robert, J Moret. <strong>Embolization of an orbital varix after surgical exposure.<\/strong> AJNR Am. J. Neuroradiol. 1998; 19: 921 &#8211; 923<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A middle age woman presented with left progressive proptosis.\u00a0 A contrast enhanced CT was done and showed enlargement of the left superior ophthalmic vein on the axial plane (see below).\u00a0 A coronal image confirmed this abnormality and demonstrated that the<\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[82,12],"tags":[41,835,70],"class_list":["post-2347","post","type-post","status-publish","format-standard","hentry","category-aunt-mickeys","category-head-and-neck","tag-ct-techniques","tag-head-and-neck","tag-orbit"],"_links":{"self":[{"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/posts\/2347","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/comments?post=2347"}],"version-history":[{"count":10,"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/posts\/2347\/revisions"}],"predecessor-version":[{"id":4257,"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/posts\/2347\/revisions\/4257"}],"wp:attachment":[{"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/media?parent=2347"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/categories?post=2347"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.ajnrblog.org\/wp-json\/wp\/v2\/tags?post=2347"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}