Spontaneous intracerebral hematoma in carotid-cavernous fistula

Report of three cases

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✓ Spontaneous intracerebral hematoma associated with carotid-cavernous fistula is rare. Three new cases are presented. In each, the hemorrhage originated in the vicinity of localized intracranial venous engorgement, as demonstrated by cerebral angiography. Rupture of one or several of the distended venous channels from increased back-flow is postulated as the etiology of the intraparenchymal hematomas.

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Address reprint requests to: Donn M. Turner, M.D., Division of Neurosurgery, University of Iowa Hospitals, Iowa City, Iowa 52242.

© AANS, except where prohibited by US copyright law.

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    Case 1. Prehemorrhage right carotid subtraction angiograms, anteroposterior (left) and lateral (right) views. There is a high-flow right carotid-cavernous fistula (large open arrow) with engorgement and rapid filling of the right superior ophthalmic vein (small open arrow) and its tributaries. Engorgement of the subfrontal pial and dural veins is also seen (large closed arrow). The right frontal cortical veins are visualized early in the arterial phase (small closed arrows), with early filling of the superior sagittal sinus.

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    Case 1. Computerized tomography scan showing a right intracerebral hematoma with blood in the frontal and occipital horns of the ventricular system. The right frontal horn is effaced and shifted across the midline. Also noted is a low-density subdural fluid accumulation over the right convexity consistent with a chronic subdural hematoma.

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    Case 1. Posthemorrhage right carotid angiograms, anteroposterior (left) and lateral (right) views. The high-flow right carotid-cavernous fistula (large open arrow), right superior ophthalmic vein (small open arrow), and subfrontal pial and dural veins (closed arrows) are again visualized as in Fig. 1. In addition to the previous findings, there is now evidence of mass effect in the frontal lobe as shown by posterior displacement of the Sylvian triangle and stretching of the frontal opercular branches of the right middle cerebral artery.

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    Case 2. Computerized tomography demonstrating a left posterior frontal intracerebral hematoma without mass effect.

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    Case 2. Left carotid angiograms, anteroposterior (left) and lateral (right) views, demonstrating a high-flow left-sided carotid-cavernous fistula (large open arrow) with early filling and distention of the left superior ophthalmic vein (small open arrow). Early filling of the left frontal cortical veins (small closed arrows) draining into the superior sagittal sinus is seen. There is extensive early visualization of many small tortuous venous structures within the brain parenchyma (large closed arrows) that remain filled until the late arterial phase and are predominantly localized to the frontal and anterior parietal regions. Mild evidence of left frontal mass effect is present.

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    Case 2. Computerized tomography scan after the second hemorrhage showing enlargement of the previous left posterior frontal intracerebral hematoma. New effacement of the left frontal horn and displacement of the left frontal horn to the right is present.

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    Case 3. Right carotid angiogram, anteroposterior (left) and lateral (right) views, demonstrating a high-flow right carotid-cavernous fistula (large open arrows) with early filling and engorgement of the right superior ophthalmic vein (small open arrows). Rapid cross-filling of the left cavernous sinus (other large open arrow) is evident. Left: Filling of the left cortical veins (small closed arrow) and left jugular vein (large closed arrow) can be seen prior to any filling of the venous structures on the right. Right: Lateral view demonstrates engorgement of the anterior pontomesencephalic vein and the veins in the vicinity of the rostral prepontine and interpeduncular cisterns (closed arrow).

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    Case 3. Computerized tomography scan displaying an area of hemorrhage near the left midbrain and left hypothalamic-thalamic regions.

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