Case 3: A Case of Right Hemiparesis after a Head Trauma

Dang Nguyen MD (*) ; Tuan Quoc Tran MD(**); Chinh Duc Nguyen MD(**); Luan Minh Tran MD(**); Cuong Chi Tran MD,PhD(**);

 (*): Cantho University of Medicine and Pharmacy VIETNAM.

(**): University of Medicine and Pharmacy at Hochiminh city VIETNAM.

Image obtained under angio-system.

What had happened to this patient ?

A. Parasitic infection.

B. Skull base calcification.

C. Foreign bodies.

D. None of above.

This was actually a case of CCF post treatment. The collections of oval opacities at the mid-skull base were contrast-filled detachable balloons which were used for embolization of the cavernous sinus.


A 26-year-old, Vietnamese, male patient sustained a motor vehicle accident 2 months ago. In the accident, he had loss of consciousness and was admitted to the local hospital. He was diagnosed with brain contusion and was indicated conservative management. He was discharged 3 week later with normal vital signs and full Glasgow comma scale. By the time of discharge, he still had right hemiparesis and minimal left eye proptosis. Approximately 1 month after being discharged, he came back to the same hospital and being referred to our medical center because of worsened proptosis. There was bruit on the left eye extending to the left temporo-parietal region.

The computed tomography angiography was done which showed left direct carotid cavernous fistula (CCF) and was confirmed by a diagnostic cerebral angiogram (Figure 1). The fistula had no drainage to the ophthalmic veins, inferior petrosal sinuses or to the other side of the cavernous sinus. There was reflux to the cortical veins of the cerebellar fossa and to the spinal veins. The fistulous cavernous sinus was markedly dilated with an appearance of pseudoaneurysm. The internal carotid artery (ICA) occlusion test was performed that showed poor collateral supply from the ipsilateral circulation to the left hemisphere. The patient was then indicated for catheterized embolization which was arranged in another session. The suggested embolic agents would be balloons or coils with attempt to preserve the ICA.

During the procedure, a 8F guiding catheter was introduced. A magic BDPE 1.2F mirocatheter that was mounted with a balloon was inserted into the cavernous sinus. Because the cavernous sinus was markedly dilated, a totally of 6 Goldbal4 balloons were detached within this pseudoaneurysmal pouch. Post embolization runs showed complete occlusion of the fistula and there were no more reflux into the spinal and cerebellar cortical veins (Figure 2). He was doing well during the hospital stay post procedure and was discharged 3 days after the embolization. The movement of his right body was similar, but the left proptosis was slightly reduced and there was no more bruit.


Typically, carotid cavernous fistula has multiple drainages into the systemic circulation via ophthalmic veins, inferior petrosal sinuses and the other side of the cavernous sinus (1). However, in a portion of cases, the fistulas are communicating into a space of the cavernous sinus which is poorly connecting to the contra-lateral side nor being well drained by other dural sinuses. Consequently, these mal-draining fistulas may cause refluxes of the drainage flow into the cerebral cortical, cerebellar and spinal veins. In our practice, the drainage reflux to the cerebellar veins happened in about 4.6 % and that into the spinal vein was at about 2.3% (2). These pathological drainages would be associated with intracranial hemorrhage (1).

There are some options for the treatment of direct CCF. Detachable balloons can be used as the first choice in some centers but coils, n-butyl cyanoacrylate and onyx would also be considered the alternative embolic materials (1, 3). In our center, most of direct CCF cases were treated with detachable balloons. It is an economic resolution comparing to using coils. In a review of 172 cases of CCF performed at the university medical center of HCM CT from 2009- 2011, the successful complete fistula occlusion rate was about 93.6% with ICA preservation in 70% of cases and the complication rate (balloon dislodgement, arterial thrombosis) was at about 1.8%. Disease recurrence happened in 9.8% but all recurrent cases were successfully treated in the second embolization. There is one case of procedural related death (0.6%) (2).


1. Berenstein A, Lasjaunias P, Brugge KGT. Traumatic arteriovenous fistula. In Kirchner E, editors. Surgical neuroangiography. 2nd ed. Germany: Springer-Verlag; 2004. p. 277-362.

2. Cuong Tran Chi. Endovascular treatment of traumatic carotid cavernous fistulas: review 172 consecutive cases. PhD thesis. Medical University of HCM CT.

3. Elhammady MS, Peterson EC, Aziz-Sultan MA. Onyx embolization of a carotid cavernous fistula via direct transorbital puncture. J Neurosurg. 2011;114(1)129-132. doi: 10.3171/2010.1.JNS091433.

Figure 1: pre-embolization images from left ICA angiogram showed pseudoaneurysm of the cavernous sinus (short arrow). Reflux into the spinal vein (arrow heads) and reflux into the cerebellar veins (long arrow). There was no drainage to the ophthalmic veins or petrosal sinuses.

Figure 2: post-embolization images showed total occlusion of the fistula. No more reflux to the cerebellar and spinal veins.