Brainstem congestion caused by direct carotid-cavernous fistula--case report

Clinical characteristics, angiographic findings and treatment outcomes of carotid cavernous fistula in Makassar, Indonesia: a single-centre experience

Background

Carotid cavernous fistula (CCF) is an abnormal arteriovenous shunt between the carotid artery or its branches, with the cavernous sinus. It is still common in developing countries, and is mostly due to traumatic origin. Endovascular treatment has emerged as the primary mode of treatment of CCF. This is the first study describing the clinical manifestation, angiographic characteristic, and the challenges we face in endovascular treatment of CCF cases in Makassar, Indonesia.

Results

This descriptive study was conducted between January 2019 to March 2022. We reviewed medical records and angiograms of all patients diagnosed with CCF at the Wahidin General Hospital, Makassar. Clinical manifestations, angiogram results, treatment, and outcome data were analyzed. A total of 23 patients were included in this study, with 17 (73.9%) direct CCF (Barrow type A) and 6 (26.1%) indirect CCF (Barrow type B, C, D). The mean age of patients were 32 years old. The three most common clinical manifestations were proptosis (n = 21, 91.3%), headache (n = 14, 60.8%), and chemosis (n = 14, 60.8%). The three most common drainage routes were via the superior ophthalmic vein (n = 23, 100%), inferior petrosal sinus (n = 12, 52.1%), and superficial middle cerebral vein (n = 6, 26.0%). All patients with direct CCF (n = 17) had endovascular treatment, resulting in 13 cases with complete occlusion (76.5%), 3 cases with incomplete occlusion (17.6%), and 1 (5.9%) procedure cancelled due to difficult navigation. Occlusion of fistula was best achieved with detachable coil, with a technical success rate of 90%. In indirect CCF (n = 6), 4 patients were treated conservatively and 2 with endovascular treatment, with complete occlusion in 2 patients.

Conclusions

Carotid cavernous fistula patients commonly presented with orbital symptoms, headache, or neuro-ophthalmologic signs. The most common drainage pattern is via anterior route. Posterior, superior and lateral drainage were not found in indirect CCF. Endovascular treatment is an effective method for fistula closure, especially in the case of direct fistula. Challenges in endovascular treatment are related to the anatomy of the fistula and cavernous sinus.

Intraoperative Monitoring of Auditory Function During Lateral Skull Base Surgery

OBJECTIVE

We present a unique case of a patient with a jugular foramen tumor with serviceable hearing. This study discusses the audiometric results and intraoperative electrocochleographic (ECochG) findings recorded during tumor removal to illustrate the potential utility of this technique in skull base surgery.

PATIENTS

A 22-year-old female patient presented with a jugular foramen schwannoma and associated symptoms of right-sided otalgia, mild hearing loss, and blurry vision.

INTERVENTIONS

Intraoperative ECochG responses during an infratemporal fossa approach: click and tone burst (1, 2, 4 kHz) stimuli were used and presented at 90 dB nHL.

MAIN OUTCOME MEASURES

Intraoperative ECochG testing using frequency-specific tone bursts and clicks before and after tumor resection.

RESULTS

The compound action potential magnitudes, cochlear microphonic, and summation potential were recorded pre- and post-tumor removal. For statistical analysis, a paired t test with significance set at p < 0.05 was used. The compound action potential magnitudes increased at all test frequencies (p < 0.01) while the summation potential and cochlear microphonic remained relatively stable (p > 0.05). Audiometric testing demonstrated an improvement of the preoperative mild right-sided hearing loss after tumor resection (pure-tone average for 0.5, 1, 2, and 4 kHz of 30 dB HL preoperation and 7.5 dB HL after tumor resection).

CONCLUSIONS

Intraoperative ECochG may allow for real-time monitoring during complex skull base surgery.

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

We describe a patient with traumatic carotid-cavernous fistula (CCF), subsequently developing contralateral extensive hemorrhagic venous infarction from retrograde venous reflux into the opposite basal vein of Rosenthal. A 54-year-old woman was involved in a motor vehicle accident and sustained severe traumatic brain injury. Two months later, she developed bilateral proptosis and audible bruit. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain demonstrated the right direct CCF. Fluid-attenuated inversion recovery (FLAIR) images showed a small hyperintense area at the left basal ganglia. Ten days later, she developed right-sided grade 2/5 hemiparesis, facial upper motor neuron weakness, and cognitive impairment. Follow-up MRI showed significant progression of hyperintensities involving the left-sided centrum semiovale, basal ganglia, thalamus, midbrain, pons, cerebellum, basal frontal, temporal lobes, especially subcortical white matter on FLAIR images, and multiple hypointense foci of hemorrhagic component on T2*-weighted gradient-echo images, representing hemorrhagic venous infarction. While waiting for embolization, she rapidly developed right hemiplegia and aphasia, and became somnolent. Under general anesthesia, emergency endovascular treatment was performed successfully to obliterate the fistula without surgical intervention. Five months after endovascular treatment, MRI and MRA confirmed no residual fistula and revealed nearly complete resolution of abnormal increased signal intensity. In the present case, the factors related to the presence of this rare condition were absence of the ipsilateral basal vein of Rosenthal (BVR), occlusion of posterior segment of the contralateral superior petrosal sinus, and a developed uncal vein with hypoplastic second and third segments of the contralateral BVR.

Epileptic Seizures Induced by a Spontaneous Carotid Cavernous Fistula

A 79-year-old woman was admitted to our emergency department with complaints of fainting and loss of consciousness three times during the past month. She was diagnosed with epilepsy and started to be treated with antiepileptic drug. Physical examination showed, in the left eye, chemosis, limited eye movements in all directions, and minimal exophthalmos as unexisting symptoms on admission developed on the sixth day. Orbital magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) imaging revealed a carotid cavernous fistula (CCF). Epileptic attacks and ophthalmic findings previously present but diagnosed during our examinations were determined to ameliorate completely after performing the coil embolization. Based on literature, we present the first case with nontraumatic CCF manifesting with epileptic seizures and intermittent eye symptoms in the present report.

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

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.

Dural Venous System in the Cavernous Sinus: A Literature Review and Embryological, Functional, and Endovascular Clinical Considerations

The cavernous sinus (CS) is one of the cranial dural venous sinuses. It differs from other dural sinuses due to its many afferent and efferent venous connections with adjacent structures. It is important to know well about its complex venous anatomy to conduct safe and effective endovascular interventions for the CS. Thus, we reviewed previous literatures concerning the morphological and functional venous anatomy and the embryology of the CS. The CS is a complex of venous channels from embryologically different origins. These venous channels have more or less retained their distinct original roles of venous drainage, even after alterations through the embryological developmental process, and can be categorized into three longitudinal venous axes based on their topological and functional features. Venous channels medial to the internal carotid artery "medial venous axis" carry venous drainage from the skull base, chondrocranium and the hypophysis, with no direct participation in cerebral drainage. Venous channels lateral to the cranial nerves "lateral venous axis" are exclusively for cerebral venous drainage. Venous channels between the internal carotid artery and cranial nerves "intermediate venous axis" contribute to all the venous drainage from adjacent structures, directly from the orbit and membranous skull, indirectly through medial and lateral venous axes from the chondrocranium, the hypophysis, and the brain. This concept of longitudinal venous axes in the CS may be useful during endovascular interventions for the CS considering our better understandings of its functions in venous drainage.

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

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.

Brainstem hemorrhage caused by direct carotid-cavernous fistula. A case report and literature review

A 34-year-old woman presented with a history of persisting headache for years, and a newly developed dizziness, left facial palsy and right hemiparesis two days prior to this admission. Initial computed tomographic angiography of the head demonstrated an area of increased density in the left middle and posterior fossae. Multiple aneurysmally dilated venous ectasias with contrast enhancement at the left pre-pontine cistern causing a massive mass effect to the brainstem were also noted, suggesting a huge vascular abnormality. Digital subtraction angiography revealed an abnormal vascular lesion surrounding the brainstem, which indicated a left direct carotid-cavernous fistula with posterior drainage. As her consciousness deteriorated the next day, a follow-up computed tomography scan was done which revealed a pontine hemorrhage. Subsequently, endovascular closure of the fistula with sacrifice of the left ICA was performed, which successfully eliminated the imaging abnormalities.

Extensive basal ganglia edema caused by a traumatic carotid-cavernous fistula: a rare presentation related to a basal vein of Rosenthal anatomical variation

The authors report a very rare presentation of traumatic carotid-cavernous fistula (CCF) with extensive edema of the basal ganglia and brainstem because of an anatomical variation of the basal vein of Rosenthal (BVR). A 45-year-old woman was admitted to the authors' institution for left hemiparesis, dysarthria, and a comatose state caused by right orbital trauma from a thin metal rod. Brain MRI showed a right CCF and vasogenic edema of the right side of the brainstem, right temporal lobe, and basal ganglia. Digital subtraction angiography confirmed a high-flow direct CCF and revealed a hypoplastic second segment of the BVR responsible for the hypertension in inferior striate veins and venous congestion. Endovascular treatment was performed on an emergency basis. One month after treatment, the patient's symptoms and MRI signal abnormalities almost totally disappeared.

Basal ganglia and brainstem venous congestion may occur in traumatic CCF in cases of a hypoplastic or agenetic second segment of the BVR and may provoke emergency treatment.

Brainstem Congestion due to Dural Ateriovenous Fistula at the Craniocervical Junction

Dural ateriovenous fistula (DAVF) at the craniocervical junction is rare. We report a patient presenting with brainstem dysfunction as an uncommon onset. Brainstem lesion was suggested by magnetic resonance image study. Angiogram revealed a DAVF at a high cervical segment supplied by the meningeal branch of the right vertebral artery, with ascending and descending venous drainage. Complete obliteration of the fistula was achieved via transarterial Onyx embolization. Clinical cure was achieved in the follow-up period; meanwhile, imaging abnormalities of this case disappeared. Accordingly, we hypothesize that a brainstem lesion of this case was caused by craniocervical DAVF, which induced venous hypertension. Thus, venous drainage patterns should be paid attention to because they are important for diagnosis and theraputic strategy.

Venous drainage patterns in carotid cavernous fistulas

Purpose. The carotid-cavernous fistula (CCF) is an abnormal arteriovenous communication and its drainage pathways may affect the clinic presentation and change treatment approach. We evaluated drainage patterns of CCFs by digital subtraction angiography (DSA) and categorized drainage pathways according to their types and etiology. Materials and Methods. Venous drainage patterns of 13 CCFs from 10 subjects were studied and categorized as anterior, posterior, superior, inferior, and contralateral on DSA. Drainage patterns were correlated to types and etiology of CCFs. Diagnosis of CCFs was first made by noninvasive imaging techniques. Results. On DSA, traumatic CCFs were usually high flow, direct type while spontaneous CCFs were usually slow flow, indirect type. Bilaterality and mixed types were observed among the indirect spontaneous CCFs. In all CCFs, anterior and inferior drainages were the most common. Contrary to the literature, posterior and superior drainages were noted only in high flow and long standing direct fistulas. Contralateral drainage was not observed in all, supporting plausible compartmentalization of cavernous sinuses. Conclusion. Types, etiology, and duration of the CCFs may affect their drainage patterns. DSA is valuable for categorization of CCFs and verification of drainage patterns. Drainage pathways may affect the clinic presentation and also change treatment approach.

Controlateral cavernous syndrome, brainstem congestion and posterior fossa venous thrombosis with cerebellar hematoma related to a ruptured intracavernous carotid artery aneurysm

Intracavernous carotid artery aneurysms (ICCAs) are rarely associated with life-threatening complications. We describe a 55-year-old woman who, after the rupture of an intracavernous carotid artery aneurysm, presented with a contralateral cavernous sinus syndrome and severe posterior fossa and spinal cord symptoms. Following parent artery occlusion, thrombosis of the posterior fossa and spinal cord veins caused a progressive worsening of the neurological status to a "locked-in" state. The patient fully recovered with anticoagulation therapy. Comprehension of the pathophysiological mechanism associated with the rupture of ICCA and early diagnosis of the related symptoms are essential in order to plan a correct treatment that includes the management of the aneurysm rupture and of possible complications related to venous thrombosis.

Brainstem compression caused by bilateral traumatic carotid cavernous fistulas: case report

BACKGROUND

Bilateral traumatic carotid cavernous fistulas (CCFs) are rare and may dilate the cavernous sinus. We present a case of brainstem compression caused by a cavernous sinus dilated by the arterial pressure of bilateral CCF.

CLINICAL PRESENTATION

A 30-year-old man suffered severe head trauma in a motorbike accident. Hemodynamically relevant, untreatable epistaxis required angiography, which revealed acute bleeding of the left sphenopalatine artery and bilateral traumatic CCFs. The bleeding was stopped by embolization with particles, and the left CCF was partially embolized to stabilize the patient hemodynamically. After short-term treatment and a long clinical course, the patient was referred to rehabilitation. Three months after trauma, the patient presented with severe headache and a dilated right pupil; he was somnolent. Immediate cerebral computed tomography scan showed a retroclival mass compressing the brainstem. Digital subtraction angiography revealed a reperfused left-sided CCF causing a huge dilatation of the retroclival cavernous sinus. After embolization with 2 balloons, the symptoms resolved and the patient was readmitted to rehabilitation.

CONCLUSION

Bilateral traumatic CCFs are uncommon. Brainstem impairment caused by venous congestion and consecutive edema is an extremely rare complication of CCFs, with only a few cases reported in the literature. Direct compression of the brainstem by CCFs has, to the best of our knowledge, never been reported before. Immediate endovascular intervention led to complete remission of the symptoms.