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

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. 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. 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. 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.