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Images in Neurology |

Carotid Cavernous Fistula Imitating Brainstem Glioma

Stephen W. Clark, MD, PhD; Toan Dang, MD; Gabor Toth, MD; Glenn L. Pride, MD; Benjamin Greenberg, MD; Worthy Warnack, MD
Arch Neurol. 2011;68(2):256-257. doi:10.1001/archneurol.2010.366.
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A 45-year old woman who had an injury from a motor vehicle crash 9 months prior to being admitted to the hospital reported experiencing 3 months of nausea and vomiting, progressive dysphagia to solids and liquids, and a 15-pound weight loss. The motor vehicle crash had resulted in skull fractures and a subarachnoid hemorrhage. On examination, she was found to be dysarthric with monotonal hypophonia and mild left-arm ataxia. Because she had an elevated creatinine level, noncontrasted magnetic resonance imaging of the brain was performed. The results showed an increased fluid-attenuated inversion recovery signal within the pontomedullary region and the left cerebellar hemisphere (Figure, A-C). Because of this finding, together with the woman's weight loss and progressive clinical course, there was concern for a neoplastic process. However, the results of magnetic resonance spectroscopy indicated brainstem edema, and the results of noncontrasted magnetic resonance imaging of the cervical spine suggested a vascular malformation (Figure, D). To further evaluate the vascular malformation, a cerebral angiogram was performed, the results of which demonstrated a direct carotid cavernous fistula (CCF) as a rare cause of the brainstem edema (Figure, E).1,2 Ten days after endovascular coiling of the CCF, the patient regained her ability to swallow and was discharged from the hospital. At home, she tolerated a regular diet and was ambulatory and self-sufficient.

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Noncontrasted axial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging involving the top of the medulla (A), lower pons (B), middle pons (C), and a sagittal view (D) demonstrating increased FLAIR signal within the pontomedullary region indicative of venous congestion. There is also evidence of dilated and serpiginous veins from the pons to C5 (D). A carotid angiogram reveals a direct carotid cavernous fistula at the posterior wall of the distal petrous and proximal cavernous internal carotid artery junction (arrow) with abnormal contrast opacification of posterior cavernous sinus (E). F, Magnetic resonance imaging after obliteration of the fistula.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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