J Korean Neurosurg Soc.  2017 Jan;60(1):89-93. 10.3340/jkns.2015.1206.001.

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

• Kamio Y
• Hiramatsu
• Kamiya M
• Yamashita
• Namba H

• KMID: 2365592
• DOI: http://doi.org/10.3340/jkns.2015.1206.001

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.

Keyword

Direct CCF; Superior petrosal sinus; Cerebellar hemorrhage

MeSH Terms

Cavernous Sinus
Cerebral Hemorrhage
Consciousness
Constriction, Pathologic
Drainage
Female
Fistula*
Hemodynamics
Hemorrhage*
Humans
Magnetic Resonance Angiography
Middle Aged
Veins
Venous Pressure

Figure

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  Fig. 1 CT bone image and 3D reconstruction (A) showing absence of the resected pterygoid process, and a bony spicule adjacent to the foramen lacerum (open circle). CT (B) and T2-weighted MRI (C) showed a left cerebellar hemorrhage and surrounding edema. CT: computed tomography, MRI: magnetic resonance imaging.

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  Fig. 2 The internal carotid artery angiogram (A) just before embolization, showing a high-flow direct carotid–cavernous fistula, engorgement of the proximal superior petrosal sinus (black arrow) and petrosal vein (black arrowhead), stenosis of the posterior segment of the superior petrosal sinus, and narrowing of the sigmoid sinus ostia (white arrow). B: Lateral view of the left carotid angiogram after embolization, showing disappearance of the fistula, cortical reflux, and occlusion of the internal carotid artery. C: Frontal view of the right internal carotid artery angiogram after embolization, showing left middle cerebral artery via anterior communicating artery and no visualization of the left internal carotid artery or the carotid–cavernous fistula.

Reference

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