Extensive basal ganglia edema caused by a traumatic carotid-cavernous fistula: a rare presentation related to a basal vein of Rosenthal anatomical variation

Case report

Isabelle RactDepartment of Radiology, Pontchaillou Hospital, CHU Rennes;

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Aurélie DrierDepartments of Neuroradiology,

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Delphine LeclercqDepartments of Neuroradiology,

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Nader SourourDepartments of Neuroradiology,

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Joseph GabrieliDepartment of Radiology, University of Padova, Italy

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Marion YgerVascular Neurology, and

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Aurélien NouetNeurosugery, Pitié-Salpêtrière Hospital, Paris VI University, Paris, France; and

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Didier DormontDepartments of Neuroradiology,

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Jacques ChirasDepartments of Neuroradiology,

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Frédéric ClarençonDepartments of Neuroradiology,

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The authors report a very rare presentation of traumatic carotid-cavernous fistula (CCF) with extensive edema of the basal ganglia and brainstem because of an anatomical variation of the basal vein of Rosenthal (BVR). A 45-year-old woman was admitted to the authors' institution for left hemiparesis, dysarthria, and a comatose state caused by right orbital trauma from a thin metal rod. Brain MRI showed a right CCF and vasogenic edema of the right side of the brainstem, right temporal lobe, and basal ganglia. Digital subtraction angiography confirmed a high-flow direct CCF and revealed a hypoplastic second segment of the BVR responsible for the hypertension in inferior striate veins and venous congestion. Endovascular treatment was performed on an emergency basis. One month after treatment, the patient's symptoms and MRI signal abnormalities almost totally disappeared.

Basal ganglia and brainstem venous congestion may occur in traumatic CCF in cases of a hypoplastic or agenetic second segment of the BVR and may provoke emergency treatment.

Abbreviations used in this paper:

BG = basal ganglia; BVR = basal vein of Rosenthal; CCF = carotid-cavernous fistula; DSA = digital subtraction angiography; ICA = internal carotid artery; SPS = superior petrosal sinus; SWAN = susceptibility-weighted angiography; TOF = time of flight.
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