A Case of Unilateral Carotid-Cavernous Fistula and Ipsilateral Hemangioma of the Orbit

A rare clinical case of combined orbital lesion is presented: carotid-cavernous fistula (CCF) and ipsilateral hemangioma in a 67-year-old patient. The differential diagnosis of CCF and orbital tumors presents certain difficulties. The gold standard for imaging this orbital pathology is computed tomography (CT) and magnetic resonance imaging (MRI) with angiography. However, these methods are expensive, not always available, have a number of limitations and contraindications, and their implementation is not always possible. Ultrasound examination (US) with assessment of blood flow is an accessible and highly informative method that allows assessing changes in blood flow in the retrobulbar vessels, differentiating avascular and vascular structures of the orbit. US in the mode of color Doppler mapping (CDM) is used in the diagnosis of CCF, which makes it possible to visualize the expansion of the diameter of the superior ocular vein (SOV) with signs of arterial blood flow and assess hemodynamic parameters in the orbital vessels. In the presented clinical case, the patient underwent ultrasound of the right orbit, which reviled an increase in the diameter of SOV in the upper-outer quadrant of the retrobulbar zone with signs of arterialization of venous blood flow in the CDM mode, which is an objective echographic sign of CCF. In the lower-outer quadrant of the orbit, a rounded formation of moderate echogenicity with clear contours was visualized, in the thickness of which vessels were not registered in the CDM mode, which corresponded to the acoustic characteristics of a benign tumor of the orbit. This clinical case is interesting because the MRI performed earlier on the patient at the first treatment did not allow a definitive diagnosis to be established, and only a comprehensive examination, including US Doppler examination, showed the presence of CCF with ipsilateral hemangioma even before using contrast-enhanced imaging techniques. Hence, the use of ultrasound in CDM mode and Doppler imaging is a highly informative method for diagnosing vascular diseases of the orbit.

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