Acute dementia as initial symptoms of bilateral indirect carotid cavernous fistula
Ting-Ying Chu, MD 1 , Poh-Shiow Yeh, MD 1 ,
1 奇美醫療財團法人奇美醫院 神經內科
1 Department of Neurology, Chi-Mei Medical Center
Ting-Ying Chu , MD
Department of Neurology, Chi-Mei Medical Center
A 80 year-old woman, without systemic illness, presented with acute progressive declination of memory and cognition over 2 weeks. Gradually, she became apathy with reduced spontaneous speech and daily activities. Occasionally, she was found to have unsteady gait or mild chemosis on left eye. Brain MRI showed unusual edema in right temporal and frontal base cortex, bilateral anterior commissure, bilateral caudate and putamen, midbrain and right aspect of the pons. The cerebral digital subtraction angiography proved bilateral indirect carotid-cavernous fistula (CCF) with venous drainage to right basal vein of Rosenthal, left superficial middle cerebral vein and retroclival venous plexus. She underwent radiosurgery, and her dementic symptoms improved after 3 month. Her follow-up brain MRI 4 months later showed regression of all parenchymal edema.
Dementia was a rare presenting symptom in patients with CCF, either unilateral or bilateral. The most common ocular symptoms of CCF, including chemosis, ophthalmoplegia, or exophthalmosis, were caused from high venous flow draining to the engorged ophthalmic veins. In our presenting case, the high venous flow unusually directed to superficial middle cerebral vein and deep venous systems, which led to severe venous edema involving mesial temporal area, anterior striate nucleus and even upper brainstem. After successful radiosurgery, the abnormal venous drainage was corrected, the parenchymal venous edema resolved gradually, and her clinical symptoms improved dramatically.