Brainstem congestion due to carotid-cavernous fistula via a shunt from the external carotid artery

Dural arteriovenous fistula of the craniocervical junction

Dural arteriovenous (AV) fistulas of the craniocervical junction can be challenging to diagnose. We describe a 70-year-old man with subacute progressive myelopathy whose MR scan of cervical spine showed serpiginous dorsal vessels, suggesting a dural AV fistula. However, a detailed diagnostic angiogram was normal, prompting additional work-up and a wider differential, which was non-revealing. His symptoms progressed over months, but the evolution of the lesion characteristics on repeat spinal imaging still suggested a dural AV fistula. Repeat angiogram identified an infratentorial dural AV fistula arising from the meningohypophyseal artery. He improved following retrosigmoid craniotomy and clipping. Initial angiography does not always demonstrate a dural AV fistula; if there is clinical and radiographic evolution, repeat angiography might identify a fistula with a rare arterial feeder.

Brainstem venous congestion due to a direct carotid-cavernous fistula: Case report

A 50-year-old male patient who, after 3 months of cranial brain trauma, presented proptosis, chemosis and exophthalmos in the left eye. Subsequently, dysmetria develops in the left extremities and right hemiparesis. The diagnosis of carotid-cavernous fistula (FCC) associated with hyperintensity of signal in FLAIR and diffuse contrast uptake at the level of the pseudo tumoral protuberance and cerebellar peduncle was established. This finding was compatible with venous congestion. His symptoms were fluctuating, he started with orbital symptoms and then from the posterior fossa with improvement of the orbital symptoms. FCC microcoil embolization produced resolution of ocular symptoms followed by improvement of brainstem symptoms. Magnetic resonance findings significantly reversed one year of follow-up. We describe a case of direct FCC with venous congestion in the brainstem and fluctuating symptoms with a considerable clinical and imaging improvement after treatment.

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.