A 45 year old man with painful right eye blindness

Teaching NeuroImagesNeurology

Resident and Fellow Section

© 2013 American Academy of Neurology

Vignette• A 45-year-old man• CC: Painful bulging right eye with redness and blindness

• Onset: 6 weeks after a motorcycle accident and traumatic brain injury

• Exam:– Complete right occulomotor nerve palsy with unreactive pupil– Visual acuity: only able to perceive light on the right

• MRI: Ipsilateral pontomesencephalic edema

• After diagnosis and treatment the 3rd nerve palsy improved and pontomesencephalic edema resolved

Alderazi YJ, et al© 2013 American Academy of Neurology

Imaging

Alderazi YJ, et al© 2013 American Academy of Neurology

Reversible Pontomesencephalic Edema caused by Traumatic Carotid Cavernous Fistula

• Catheter angiography showed a direct right carotid-cavernous fistula (CCF) with venous drainage into (Figure 1C).

• Two months after embolization of the CCF, the ptosis, proptosis and painful ophthalmoplegia resolved.

• MRI revealed complete resolution of pontomesencephalic edema (Figure1D).

• The presumed mechanism of the pontine edema was transmission of arterialized pressures of the cavernous sinus via a bridging vein to the anterior pontomesencephalic vein , generating venous hypertension and vasogenic edema [1,2]

• Teaching point: If you see pontine edema with the above clinical presentation, think of CCF!

Alderazi YJ, et al© 2013 American Academy of Neurology