Brainstem edema caused by traumatic carotid-cavernous fistula: A case report and review of the literature

Abstract

Abstract. Brainstem edema caused by traumatic carotid-cavernous fistula (TCCF) is rare, and there is little information available regarding its clinical characteristics. The present report describes the case of a 51-year-old man with TCCF, who presented with right exophthalmos and intracranial bruit for 1 week. One month prior to admission at hospital, he fractured the frontal and ethmoid sinuses. Digital subtraction angiography confirmed the diagnosis of TCCF, and magnetic resonance imaging (MRI) suggested edema on the right side of the pons. Five days after admission, the patient exhibited left hemiparesis, and MRI revealed aggravation of the brainstem edema. Following treatment with transarterial balloon embolization, the clinical symptoms, including hemiparesis, were relieved; at the 1-month follow-up, the brain edema had disappeared. The patient was normal at the 6-month follow-up. Following the report of the present case, we reviewed six additional cases previously reported in the literature and discussed the potential mechanisms of TCCF-associated brainstem edema. We conclude that occlusion of the superior petrosal sinus may contribute to brainstem edema caused by TCCF. Relief of the brainstem edema and brainstem edema-associated clinical symptoms can be achieved with transarterial coil or balloon embolization of the TCCF to reduce the drainage pressure in the brainstem veins.

Republished: Primary intraventricular haemorrhage due to rupture of giant varix of the basal vein of Rosenthal in a patient with long-standing direct CCF: angiographic features and treatment considerations

“…If only the anterior striate segment is present and decompresses the cavernous sinus via the uncal vein with reflux into striate veins, extensive basal ganglia oedema may result 7. When the mesencephalic segment alone is absent, the lateral mesencephalic vein may act as an anastomosis between the peduncular segment and the posterior fossa veins resulting in brainstem oedema or haemorrhagic infarction 8 9. In our case, the draining basal vein lacked a mesencephalic segment, and the uncal vein directly emptied into its anterior segments with no communication with striate veins and only minor reflux into the frontobasal veins.…”

Contralateral extensive cerebral hemorrhagic venous infarction caused by retrograde venous reflux into the opposite basal vein of Rosenthal in posttraumatic carotid-cavernous fistula: A case report and literature review

“…The data, including the sex, age, cause and side of fistula, location and side of brain edema, sinuses and/or veins involved, presence of hemorrhage, methods of treatment, and outcome of patients are described in Table 1. 6,8,[14][15][16][17][18][19][20][21][22][23] Including our one case, there were 14 cases (7 females and 7 males) with a median age of 48 years (range 24-88 years). Out of 14 fistulas, 8 were the result of traumatic causes, 5 spontaneous, and 1 iatrogenic.…”

“…8,16 The SPS was not identifiable in another five cases, and probably thrombosed. 6,8,14,21,22 Interestingly, Chan et al 12 reviewed brainstem dysfunction with venous congestion and/or hemorrhage caused by CCF (i.e. 9 direct and 13 indirect fistulas).…”

“…5 Rarely, aggressive neurologic symptoms, especially deterioration of consciousness, may also develop due to cerebral ischemia and/or hemorrhage. 6,7 Cerebral ischemia in traumatic or direct CCF may result from arterial or venous cause. The arterial infarction from stealing of blood flow by direct CCF usually occurs in the ipsilateral carotid territory.…”

“…5 Rarely, aggressive neurologic symptoms, especially deterioration of consciousness, may also develop due to cerebral ischemia and/or hemorrhage. 6,7…”