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July 08, 2014; 83 (2) Resident and Fellow Section

Teaching NeuroImages: Reversible pontomesencephalic edema caused by traumatic carotid cavernous fistula

Yazan J. Alderazi, Sushrut Dharmadhikari, Diogo C. Haussen, Dileep R. Yavagal
First published July 7, 2014, DOI: https://doi.org/10.1212/WNL.0000000000000562
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A 45-year-old man presented with a painful bulging right eye and blindness 6 weeks after a motorcycle accident and traumatic brain injury. He had a complete right oculomotor nerve palsy and only perception of light. MRI revealed ipsilateral pontomesencephalic edema (figure, A and B). Catheter angiography showed a direct right carotid-cavernous fistula (figure, C). Two months after coil embolization, the ptosis, proptosis and ophthalmoplegia resolved. MRI revealed resolution of pontomesencephalic edema (figure, D). The presumed mechanism was transmission of arterialized pressures of the cavernous sinus via a bridging vein to the anterior pontomesencephalic vein, generating venous hypertension and vasogenic edema.1,2

Figure
Figure Pretreament pontomesencephalic lesion

(A) Fluid-attenuated inversion recovery and (B) T1 postcontrast MRI. (C) Carotid-cavernous fistula drainage via bridging veins (arrow) to the anterior pontomesencephalic vein (interrupted arrow) and via superior ophthalmic vein (arrowhead) and pterygoid plexus (double arrows) on catheter angiography, lateral view. (D) Pontomesencephalic edema resolution on post-treatment MRI.

AUTHOR CONTRIBUTIONS

Study concept and design: Y.J.A., D.Y. Acquisition of data: Y.J.A. Analysis and interpretation of data: Y.J.A., S.D., D.C.H. Drafting of the manuscript: Y.J.A., S.D. Critical revision of the manuscript for important intellectual content: S.D., D.C.H., D.Y. Study supervision: D.Y.

STUDY FUNDING

No targeted funding reported.

DISCLOSURE

The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.

Footnotes

REFERENCES

  1. 1.↵
    1. Kiyosue H,
    2. Tanoue S,
    3. Sagara Y,
    4. et al
    . The anterior medullary-anterior pontomesencephalic venous system and its bridging veins communicating to the dural sinuses: normal anatomy and drainage routes from dural arteriovenous fistulas. Neuroradiology 2008;50:1013–1023.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Kiyosue H,
    2. Mori H,
    3. Sagara Y,
    4. et al
    . Basal cerebral venous drainage from cavernous sinus dural arteriovenous fistulas. Neuroradiology 2009;51:175–181.
    OpenUrlCrossRefPubMed
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