PMC9479522_01
(a-d) Sequential axial images of non-contrast computed tomography scan, and (e and f) axial and (g) sagittal T2-weighted magnetic resonance images of the brain reveal markedly enlarged left sphenoparietal sinus and cortical veins along left cerebral hemisphere. There is some venous wall calcification. (h) Photograph of the patient's left-sided neck in oblique view shows the previous surgical scar.
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F1
There was some venous wall calcification [Figures 1a-g]. Physical examination revealed the previous surgical scar at the left side of her neck [Figure 1h].
Cerebral angiography before treatment. (a) Anteroposterior (AP) and (b) lateral views of the left common carotid artery, (c) AP view of the right internal carotid artery (ICA), and (d) lateral views of the left vertebral artery with (e) 3D reconstruction angiographic computerized tomography reveal the left direct high-flow carotid-cavernous fistula supplied by the contralateral ICA through the anterior communicating artery, vertebrobasilar system through posterior communicating artery, and ipsilateral ICA through multiple small vascular channels, representing the revascularization of the left ICA through vasa vasorum, at the level of C3-C4. The venous drainage exclusively drains into markedly dilated tortuous cortical veins along left cerebral hemisphere. There is no existence of the left external carotid artery.
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F2
Trolard, and the left transverse sinus through the vein of Labbe [Figure 2]. The fistula was also supplied by the contralateral
3D reconstruction images in (a) anterior, (b) posterior, (c) right lateral, and (d) left lateral views, and maximum intensity projection reformatted images in (e) axial, (f) sagittal, and (g) coronal views of angiographic computerized tomography of the left common carotid artery clearly demonstrate multiple small serpiginous vessels, hypertrophied vasa vasorum, projecting over expected course of the internal carotid artery (ICA) with antegrade filling of the distal ICA.
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F3
ICA through the anterior communicating artery (ACoA) and vertebrobasilar system through posterior communicating artery (PCoA). In addition, 3D reconstruction and maximum intensity projection reformatted images of angiographic CT of the left CCA clearly illustrated multiple small serpiginous vessels, hypertrophied vasa vasorum, projecting over expected course of the ICA with antegrade filling of the distal ICA [Figure 3].
Cerebral angiography obtained 1 year after treatment. (a) Anteroposterior (AP) and (b) lateral views of the left common carotid artery, (c) AP view of the right internal carotid artery, and (d) lateral views of the left vertebral artery injections confirm complete obliteration of the fistula.
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F4
Follow-up cerebral angiography, obtained 1 year after the second embolization, confirmed no recurrence of the fistula [Figure 4].