Cerebellar Hemorrhage due to a Direct Carotid–Cavernous Fistula after Surgery for Maxillary Cancer

Abstract

Infratentorial cerebral hemorrhage due to a direct carotid–cavernous fistula (CCF) is very rare. To our knowledge, only four such cases have been reported. Cerebellar hemorrhage due to a direct CCF has not been reported. We describe a 63-year-old female who presented with reduced consciousness 3 days after undergoing a maxillectomy for maxillary cancer. Computed tomography showed a cerebellar hemorrhage. Magnetic resonance angiography showed a left-sided direct CCF draining into the left petrosal and cerebellar veins through the left superior petrosal sinus (SPS). Her previous surgery had sacrificed the pterygoid plexus and facial vein. Increased blood flow and reduced drainage could have led to increased venous pressure in infratentorial veins, including the petrosal and cerebellar veins. The cavernous sinus has several drainage routes, but the SPS is one of the most important routes for infratentorial venous drainage. Stenosis or absence of the posterior segment of the SPS can also result in increased pressure in the cerebellar and pontine veins. We emphasize that a direct CCF with cortical venous reflux should be precisely evaluated to determine the hemodynamic status and venous drainage from the cavernous sinus.

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

“…Similarly, our case and another five cases from our review had occlusion or hypoplastic posterior segment of the SPS, resulting in edema of brainstem, cerebellum, and/or spinal cord. 8,16,19,23 Three of five cases were confirmed spontaneous thrombosis of the SPS because prior angiography revealed the patent SPS. 8,16 The SPS was not identifiable in another five cases, and probably thrombosed.…”

“…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.…”

“…It may be secondary to increased venous pressure or venous congestion from the redirection of the venous outflow through the valveless veins or sinuses after some conditions, for example, sacrificing of some draining veins, thrombosis of the CS or draining veins, or stenosis of venous outlet. 8,23,24 Kamio et al 23 demonstrated that cerebellar hemorrhage with surrounding edema resulted from direct CCF after performing maxillary surgery involving sacrifice of ipsilateral facial vein and pterygoid plexus. Sacrifice of these veins may alter the venous drainage and increase venous pressure in infratentorial veins.…”

“…25 Therefore, the SPS provides an important route for infratentorial venous drainage from the brainstem and cerebellum via the petrosal vein. 23 SPS was divided into anterior and posterior segments. 26 Hypoplasia or occlusion of this sinus may promote venous congestion of the venous system in surrounding brainstem, leading to edema and/or hemorrhage of brainstem and/or cerebellum.…”

“…26 Hypoplasia or occlusion of this sinus may promote venous congestion of the venous system in surrounding brainstem, leading to edema and/or hemorrhage of brainstem and/or cerebellum. 8,16,19,23 Importantly, incomplete closure of direct CCF should be avoided due to the possibility of the rerouting of venous drainage into cortical or deep venous systems, leading to cerebral edema and/or hemorrhage, rather than resolution of the fistula. Further complete obliteration of the residual fistula or drainage should be achieved when possible.…”