Ultrasound in Med. & Biol.. Vol. 22, No. 9, pp. t IX- 1162, 1996 Copyright 0 1996 World Federation for Ultrasound in Medicine & Biology Printed in the USA. Ail rights reserved 0301.56?9/96 $15.00 + .OO ELSEVIER PII: SO301-5629(96)00152-4 @Original Contribution DIAGNOSIS AND FOLLOW-UP OF CAROTID-CAVERNOUS FISTULAS BY CAROTID DUPLEX SONOGRAPHY AND TRANSCRANIAL COLOR DOPPLER IMAGING Yu-WEI CHEN,’ JIANN-SHING JENG, HON-MAN LIU, PING-KEUNG YIP, BAO-SHOW HWANG, WIN-HWAN LIN, YANG-CHYAN CHANG and YONG-KWANG Tu Departments of Neurology, Radiology and Surgery, National Taiwan University Hospital, Taipei, Taiwan (Received 21 March 1996; injnalform 8 July 1996)) Abstract-To investigate the suitability of extracranial carotid duplex (ECD) and transcranial color Doppler imaging (TCDI) in the diagnosis and follow-up of treatment in patients with carotid-cavernous list&s (CCF), combined ECD and TCDI examinations were studied in seven patients with traumatic CCF. According to angiograpby, four patients bad direct CCF, two indirect CCF and one both direct and indirect CCF. In ECD, bemodynamic parameters of the feeding artery showed an abnormally increased flow volume and decreased resistivity indices in five direct CCFs from the internal carotid artery and one indirect CCF from the external carotid artery. Direct visualization of the CCF was achieved in patients with direct CCF only, and revealed itself as a heterogeneous mosaic flash resulting from high flow velocities and turbulence. Patterns of venous drainage were detected via the transorbital and transforaminal windows in seven and five patients (four direct and one indirect CCF patients), respectively. These abnormal findings were improved or even normalized after successful treatment. In conclusion, combined ECD and TCDI examina- tions appear to be useful for the diagnosis and follow-up of CCF. Copyright 0 1996 World Federation for Ultrasound in Medicine & Biology. Key Words: Arteriovenous fistula, Carotid-cavernous sinus, Ultrasonograpby, Doppler, Duplex, Trans- cranial. INTRODUCTION Carotid-cavernous fistulas (CCFs) are abnormal con- nections between the carotid artery and the cavernous sinus (CS) and are either spontaneous or traumatic in nature. On the basis of angiographic findings, Barrow et al. ( 1985) provided a detailed anatomical classifica- tion of four types of CCF, with type A being a direct connection between the internal carotid artery (ICA) and CS and types B, C and D being dural or indirect shunts. Type B is a dural shunt between the CS and meningeal branches of the ICA, type C is a dural shunt between the CS and meningeal branchesof the external carotid artery (ECA), and type D is a fistula between the CS and dural branches of both the ICA and ECA. Although CCFs can be evaluated by computerized to- mography and magnetic resonance imaging, carotid ’ Present address for Y.W. Chen: Department of Medicine, Li- Hsin Hospital, Ping-Chen City, Tao-Yuan County, Taiwan. Address correspondence to: Ping-Keung Yip, M.D., Depart- ment of Neurology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan. E-mail: ywchen ccms.ntu.edu.tw angiography remains the main diagnostic tool for the definite diagnosis of the direct or indirect shunting of CCF. However, it is impractical to carry out this inva- sive procedure repeatedly during follow-up of the clini- cal course and evaluation of the response to treatment, especially when the conditions of the patients are clini- cally stable or even normal. For these reasons, vascular ultrasonography is considered to be an ideal and possi- ble alternative. Because of its special location and rela- tionship to the arteriovenous system, direct visualiza- tion of the CCF and its hemodynamic characteristics may be facilitated by modem neurosonography. Extra- cranial carotid duplex (ECD) (Lin et al. 1994a) and transcranial Doppler sonography (Muttaqin et al. 1992; Sommer et al. 1992) have been used in the diagnosis and hemodynamic classification of CCF and the direct monitoring of the flow characteristics of fistulas, re- spectively. Transcranial Doppler can also provide a noninvasive method for objective assessment after in- tervention (Burger et al. 1993; Gomez et al. 1989). Recently, the combined application of ECD and the more advanced transcranial color Doppler imaging (TCDI) was suggested to provide more accurate re- 1155