J Cerebrovasc Endovasc Neurosurg.  2021 Sep;23(3):251-259. 10.7461/jcen.2021.E2020.10.006.

Delayed intracerebral hemorrhage from a traumatic carotid-cavernous fistula associated with an enucleated orbit

• Bram R
• Chaudhry N
• Choi JL
• Atwal G

• KMID: 2520885
• DOI: http://doi.org/10.7461/jcen.2021.E2020.10.006

Abstract

Spontaneous intracerebral hemorrhage (ICH) from a traumatic carotid-cavernous fistula (CCF) is a rare occurrence with few cases reported in the literature. Patients classically present shortly after the inciting trauma with symptoms of ocular venous hypertension. We report a case of an ICH due to delayed rupture of a venous aneurysm from a CCF in a patient with decades-old history of enucleation of the left globe secondary to trauma with no sentinel symptoms. Our patient represents a unique presentation of a rare pathology. This case highlights the need for ongoing surveillance in patients with a history of severe craniofacial trauma, as ICH from ruptured CCF(s) demands emergent treatment due to the potential for rapid neurological deterioration.

Keyword

Carotid-cavernous fistula; Intracerebral hemorrhage; Traumatic fistula; Venous hypertension; Orbital trauma

Figure

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  Fig. 1. Axial CTA reveals cavernous sinus venous sacs and a dilated deep venous system (A). A venous network in the temporal lobe with connections to superficial cortical veins (B). Axial and coronal images show a periventricular venous varix arising from the thalamostriate vein (C, D). CTA, computed tomography angiogram.

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  Fig. 2. AP DSA of the right ICA in the arterial phase shows rapid cross-flow through the anterior communicating artery complex into the CCF (A). There is evidence of venous hypertension as manifested by the dilation of both deep and superficial venous systems (B, C). Lateral DSA of the left CCA shows proximal ICA occlusion with supply of the CCF by way of ICA and ECA feeders (D). Oblique DSA of the right ICA and AP DSA of the right vertebral artery show flow-related aneurysms in the right A2 segment of the anterior cerebral artery and the basilar apex (E, F). AP, anteroposterior; DSA, digital subtraction angiography; ICA, internal carotid artery; CCF, carotid-cavernous fistula; CCA, common carotid artery; ECA, external carotid artery.

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  Fig. 3. Oblique unsubtracted view shows the combined Onyx-Coil mass (A). AP and lateral DSA of the right ICA after embolization shows near-complete occlusion of the CCF with no further evidence of retrograde venous reflux. The ACA territory fills from the right ICA bilaterally and there is faint filling of the left MCA territory from the right ICA injection (B, C). AP DSA of the left vertebral artery after embolization demonstrates filling of the left MCA territory by the posterior circulation via the posterior communicating artery (D). AP, anteroposterior; DSA, digital subtraction angiography; ICA, internal carotid artery; CCF, carotid-cavernous fistula; ACA, anterior cerebral artery; MCA, middle cerebral artery.

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  Fig. 4. Post-procedural axial computed tomography (CT) scan shows evidence of an expanding hematoma, IVH and midline shift (A). Post-operative axial CT scan after decompressive hemicraniectomy for hematoma evacuation (B). IVH, intraventricular hemorrhage.

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