Carotid-cavernous fistula with an uncommon presentation: obstructive hydrocephalus

Case Presentation: LLS, 25 years old, male, presented at the ER with severe headache, vomits, tetraparesis grade two and stupor. Head CT showed us supratentorial hydrocephalus, sign of ependimary transudation and collapse of IV ventricle secundary a mass in posterior fossa.

Discussion: After a VP shunt, a better history and physical examination were performed due to an improvement on the level of consciousness. Further data was found in his examination so as pulsating exophthalmos, orbital blow, low cranial nerves impairment, tetraparesis with pyramidal signs and history of brain trauma three years ago. Additional propaedeutic were fulfilled. Head MRI demonstrate increased vascular mesh mostly at the posterior fossa associated with a mass located on its floor, significant adjacent edema and compression of the brainstem. This mass presented partial enhancement with gadolinium and was continuous with the vascular mesh cited above suggesting be a thrombosed vein. Digital subtraction angiography was done and revealed a carotid-cavernous fistula at left ICA. Carotid occlusion test showed that was no decrease on cerebral blood flow. Definitive carotid occlusion was perfomed by our intervencionist neuroradiology team by using coils with no complications. Two weeks after procedure, the pacient demonstrate no dysphonia, no dysphagia, tetraparesis grade four, walking with some help. VP shunt working well at discharge from hospital. Physical therapy rehabilitation and outpatient follow-up were proposed.

Final Comments: 8-Month follow-up, patient presented no neurological impairment, muscular strength preserved with a subcutaneous infection at the peritoneal cateter due to an appendicitis that was treated in another hospital. Head CT without pathological alterations. The VP Shunt was removed. We started venous antimicrobials for two weeks to treat infection. Patient showed no signs/symptoms suggesting a hydrocephalus during the treatment of infection. This case above revealed an uncommon presentation of a cavernous-carotid fistula – with a range of signs and symptoms – on account of the delayed time between the head trauma and the medical assistance. Fortunately, this patient had a good outcome. A brief research at Pubmed.com demonstrate to us that was no clinical cases like this above. We would like to thank the whole team of vascular neurosurgery and interventional neuroradiology for the contribution to this clinical case.