ABSTRACT
INTRODUCTION@#Cavernomas in the brainstem and spinal cord are rare than their intracranial counterparts, and occurrences specifically at the cervicomedullary junction are infrequent. In this report, we present a case of a cervicomedullary cavernoma which manifested with spinal shock and dysfunction.@*CASE REPORT@#We describe a patient who exhibited spinal shock syndrome and a stepwise decline in spinal cord function. A 33-year-old woman initially complained of right upper arm and occipital referred pain from the atlantoaxial region. Three days later, she experienced bowel and urinary incontinence. Subsequently, quadriparesis and numbness affecting all limbs developed after one week, followed by life-threatening respiratory depression after nine days. Magnetic resonance imaging revealed a lesion in the cervicomedullary junction, identified as a cavernous hemangioma. During the hospital stay, fragmented reflex activity gradually returned. Upon follow-up, the bowel and urinary incontinence, motor impairments, and sensory impairments showed improvement.@*CONCLUSION@#The proposed mechanism for the mass effect of this cavernous malformation on the spinal cord at the cervicomedullary junction was likely due to pressure effects caused by shifting dynamics. Understanding the natural history of cavernous malformations, regional neurovascular anatomy, safe entrance points to the brainstem, routes to the craniovertebral junction from the base of the skull, and specific microsurgical procedures for their removal are necessary for appropriate treatment. However, these considerations should be balanced against knowledge of the associated hazards and treatment recommendations.
ABSTRACT
@#Carotid-cavernous fistula (CCF) is a rare and dangerous neurological disorder that arises due to an abnormal communication between the internal carotid artery (ICA) or the external carotid artery (ECA) and their branches and the cavernous sinus. It can either be a direct fistula (high-flow with acute symptoms) most commonly resulting from trauma (70-90%) or an indirect fistula (low-flow with insidious symptoms) secondary to hypertension, atherosclerosis and collagen vascular disorders. The shunting of arterial blood into the venous system leads to venous hypertension causing various clinical manifestations depending on the venous drainage patterns and the shunt flow. Increased anterior, posterior and superior venous drainage results to orbital/ocular, cavernous and cortical symptomatology, respectively. This paper aims to present a case of 58-year old Filipino female with a 2-day history of sudden, severe headache, vomiting and blurring of vision followed by decrease in sensorium and sudden proptosis and chemosis of the left eye. Patient had no co-morbidities, history of trauma, surgeries, facial skin infections or prior febrile illness. The left eye had exophthalmos, subconjunctival hyperemia, scleral edema/chemosis and ocular bruit. Neurologic examination showed a stuporous patient with multiple cranial nerve deficits (impaired direct and consensual pupillary reflex left, complete ptosis left, sluggish corneal reflex left, impaired oculocephalic reflex left), right hemiplegia and meningeal signs. Cranial Computed Tomography (CT) Angiogram revealed an acute parenchymal hemorrhage in the left frontotemporal lobe with subarachnoid component, with engorged left cavernous sinus and dilated left superior ophthalmic vein. Digital Subtraction Angiography (DSA) was done revealing a direct type of left carotid-cavernous fistula with massive ICA shunting to the cavernous sinus, superior ophthalmic vein and inferior petrosal sinus. The clinical and radiographic evidence were consistent with a Direct/Type A CCF. Unique in this case was a patient with no history of trauma presenting with simultaneous orbital/ocular, cavernous and cortical symptomatology – a clinical picture of CCF that has never been documented in any literature nor included in any classification system. The presence of all three symptomatology can be explained by a direct/highflow fistula that resulted to increased anterior, posterior and superior venous drainage as documented in the DSA. In addition, spontaneous intracranial hemorrhage in CCF is exceptionally rare and it is the most daunting symptomatology of this disease. With that, this specific case may pave the way to a new classification scheme and determine its corresponding treatment approach.