PMC5791513_01
(a) Anterior-posterior and lateral cerebrocervical angiograms of right ICA injection showing right ICA dissection and CCF near the petrous and cavernous portion of the right ICA without drainage into the superior ophthalmic vein or into the inferior petrosal sinus. (b) Angiogram of left ICA injection on day 1 of admission and angiogram of right ICA injection on day 21. There is vasospasm of the left A1 segment near its origin on day 1 which resolved by day 21
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F1
There was no evidence of retrograde venous drainage into the right superior ophthalmic vein (SOV) or the right inferior petrosal sinus at this time [Figure 1a]. There was evidence of vasospasm of the A1 segment of the left anterior cerebral artery (ACA) [Figure 1b].
Follow-up head CT on the day of admission shows extensive SAH as well as an epidural hematoma that required evacuation
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F2
The patient was then transferred to the ICU for management of intracranial pressure (ICP); a follow-up CT later that evening showed a right epidural hematoma which required evacuation [Figure 2].
(a) Lateral cerebral angiogram of right ICA injection showing early venous drainage through the right CCF with retrograde filling of the right SOV. Note evidence of vasospasm along the right communicating portion of the ICA and the right M1. (b) Anterior-posterior cerebral angiogram of left ICA injection showing no flow into the left ACA due to severe vasospasm of the left A1 segment and mild to moderate vasospasm of the left ICA and M1 segment of the left MCA. (c) Anterior-posterior cerebral angiogram of right ICA injection showing mild vasospasm of the right ICA and M1 segment of the right MCA. There is no evidence of retrograde cortical venous drainage
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F3
Although postprocedural arteriograms revealed successful embolization of the left SOV, there was retrograde filling of the right SOV which was not previously observed [Figure 3a]. There was evidence of mild-to-moderate vasospasm involving the left ICA, M1, and A1 [Figure 3b], whereas the vasospasm involving the right was less severe [Figure 3c].
Anterior-posterior cerebral angiogram of right ICA injection after left ICA and left cavernous sinus occlusion showing antegrade flow into both anterior circulation. The venous phase on the left was delayed by 1 second compared to the right side. There continues to be evidence of retrograde cortical venous drainage from the right cavernous sinus into the right superficial middle cerebral vein
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F4
Although there was no longer any evidence of retrograde corticovenous drainage on the left, the right superficial middle cerebral vein filled retrograde from the right ICA injection [Figure 4].
(a) Microscope photograph showing the arterialized right superficial middle cerebral vein. (b) Microscope photograph showing the right superficial middle cerebral vein after it was clipped, cauterized, and cut
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F5
Instead, we performed a right craniotomy and ligated the arterialized right superficial middle cerebral vein at the fistula site [Figure 5a and b] to protect the brain from potential venous infarction.
Three-month follow-up anterior-posterior cerebral angiogram of right ICA injection reveals good collateral flow into the left anterior circulation via the Acomm with retrograde flow through the residual left CCF into the cavernous sinus
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F6
However, there was residual filling of the left CCF via retrograde flow from the right anterior circulation across the Acomm [Figure 6].