Brainstem Compression Caused by Bilateral Traumatic Carotid Cavernous Fistulas: Case Report

BACKGROUND: Bilateral traumatic carotid cavernous fistulas (CCFs) are rare and may dilate the cavernous sinus. We present a case of brainstem compression caused by a cavernous sinus dilated by the arterial pressure of bilateral CCF. CLINICAL PRESENTATION: A 30-year-old man suffered severe head trauma in a motorbike accident. Hemodynamically relevant, untreatable epistaxis required angiography, which revealed acute bleeding of the left sphenopalatine artery and bilateral traumatic CCFs. The bleeding was stopped by embolization with particles, and the left CCF was partially embolized to stabilize the patient hemodynamically. After short-term treatment and a long clinical course, the patient was referred to rehabilitation. Three months after trauma, the patient presented with severe headache and a dilated right pupil; he was somnolent. Immediate cerebral computed tomography scan showed a retroclival mass compressing the brainstem. Digital subtraction angiography revealed a reperfused left-sided CCF causing a huge dilatation of the retroclival cavernous sinus. After embolization with 2 balloons, the symptoms resolved and the patient was readmitted to rehabilitation. CONCLUSION: Bilateral traumatic CCFs are uncommon. Brainstem impairment caused by venous congestion and consecutive edema is an extremely rare complication of CCFs, with only a few cases reported in the literature. Direct compression of the brainstem by CCFs has, to the best of our knowledge, never been reported before. Immediate endovascular intervention led to complete remission of the symptoms.