Neurointervention.  2024 Nov;19(3):185-189. 10.5469/neuroint.2024.00318.

Delayed Pontomesencephalic and Cervical Cord Venous Drainage Followed by Contralateral Carotid-Cavernous Fistula after Craniofacial Fractures: A Case Report

• Tandean S
• Harsan H
• Siahaan AMP
• Septian H
• Josethang A

• KMID: 2560224
• DOI: http://doi.org/10.5469/neuroint.2024.00318

Abstract

A 24-year-old male was admitted with progressive cervical hypesthesia, tetraparesis, dyspnea, and a history of craniofacial fracture. Spinal magnetic resonance imaging (MRI) showed brainstem edema extending to the thoracic spine with multiple prominent perimedullary vascular structures. Cerebral digital-substraction angiography revealed Barrow type A carotid-cavernous fistula. Total occlusion with preservation of internal carotid artery flow was achieved using 1 detachable balloon and 6 coils. Postoperatively, immediate respiratory recovery, gradual extremities strength improvement, and right abducens nerve palsy were found. One month follow-up cervical MRI showed good recovery of spinal cord edema and perimedullary veins.

Keyword

Trauma; Carotid-cavernous fistula; Delayed myelopathy

Figure

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  Fig. 1. (A) T2 Sagittal cervical magnetic resonance imaging (MRI): edema of medulla oblongata and cervicothoracic spinal cord and serpentine like signal void structure (suggesting peri medullary vein enlargement) (white arrows). (B) Right internal carotid artery (right anterior oblique view): abnormal filling of the cavernous sinus (CS, black arrow) with an associated aneurysm consistent with direct carotid-cavernous fistula. No anterior drainage, prominent reflux into the superior petrosal sinus (black arrowheads) - inferior petrosal sinus (empty arrow) and peri medullary veins noted. (C) Goldbal2 detached inside the CS. (D) After detaching 3 detachable coils - not fully occluded fistula. (E) Lateral view after adding another 3 detachable coils. (F) Cervical spinal MRI scan after 1 month of treatment showing recovery of spinal cord edema and disappearance of the perimedullary veins.

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