Direct carotid-cavernous fistula presenting with intracranial hemorrhage without ocular symptoms

• Published in: Radiology case reports Vol. 19; no. 6; pp. 2418 - 2421
• Main Authors: Mori, Tatsuya, Fujita, Atsushi, Iwahashi, Hirofumi, Ikeda, Mitsuru, Morikawa, Masashi
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01-06-2024; Elsevier
• Subjects: Direct carotid-cavernous fistula; Intracerebral hemorrhage; Superficial middle cerebral vein; Transvenous embolization; TVE; ICA; CCF; MCA; SMCV; IPS; Intracerebral hemorrhage; Transvenous embolization; Superficial middle cerebral vein; ICH; CS; Direct carotid-cavernous fistula; TAE; SOV; MRA; ACA
• ISSN: 1930-0433; 1930-0433
• DOI: 10.1016/j.radcr.2024.02.111

Herein, we report a unique case of nontraumatic direct carotid-cavernous fistula presenting with intracerebral hemorrhage without any ocular symptoms. A 90-year-old woman was found unconscious and vomiting due to a subcortical hemorrhage in the temporal lobe. Magnetic resonance angiography revealed a direct carotid-cavernous fistula of Barrow type A. Extensive cortical venous reflux from the superficial middle cerebral vein was observed and identified as a probable contributor to the cerebral hemorrhage. We performed successful embolization using combined transarterial and transvenous approaches. We first occluded the dangerous venous drainage via the transvenous approach, followed by selective occlusion of the direct carotid-cavernous fistula via the transarterial approach. This strategy provided that the dangerous venous drainage was completely occluded first in case complete obliteration could not be achieved with the transarterial approach.