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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.
Clark SW, Dang T, Toth G, Pride GL, Greenberg B, Warnack W. Carotid Cavernous Fistula Imitating Brainstem Glioma. Arch Neurol. 2011;68(2):256-257. doi:10.1001/archneurol.2010.366