Value of 3D-TOF MR angiography and 4D-dynamic contrast-enhanced MRI in the assessment of spontaneous posterior cavernous sinus dural arteriovenous fistula

A 46-year-old female patient presented symptoms of complete right oculomotor nerve palsy without proptosis. Orbital magnetic resonance (MR) imaging showed no abnormalities. 3D time-of-flight MR angiography revealed high signal intensity in the right cavernous sinus . This isolated finding has a 10-15% rate of false-positive in the diagnosis of dural arteriovenous fistula (DAVF). Additional 4D-dynamic contrast-enhanced MR angiography evidenced an early asymmetric enhancement of bilateral cavernous sinus, mainly on the right, draining downward through the inferior petrous sinus. Digital subtraction angiography confirmed a posterior cavernous sinus DAVF, and endovascular treatment was prescribed.