Postoperative Intracranial Hemorrhage after Obliteration of Traumatic Carotid Cavernous Fistula with Total Steal of Blood Flow Department of Neurosurgery, Changhai Hospital, SMMU Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report 51-year-old, male Traumatic cranial injury with loss of consciousness for one hour PE: nothing significant except for scalp contusion Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report Cerebral contusion of the right frontal lobe and fracture of the frontal bone Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report 2 wks latter Intracranial bruits Progressive proptosis, chemosis & vision acuity declining in the left eye Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report CTA Abnormal enhancement of the left cavernous sinus with tortuous vessels DSA Direct traumatic carotid cavernous fistula Cortical venous reflux via the left sylvian vein Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report Failed in balloon occlusion of TCCF in the local hospital Post-oper. Pre-oper. Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report Sudden aphasia and progressive weakness for 20 hrs before admission to our institute Pre-operative anti-platelet preparation for covered stent deployment with aspirin and Plavix for 3 days before transfer Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report Neurological examination –Alert, total motor aphasia –Proptosis and chemosis in the left eye –Vision acuity of the left eye HM at 30 cm –No intracranial bruits –Right central facial paralysis & hemiparesis Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report CT immediately after admission didn’t show any sign of hemorrhage Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report MRI immediately after admission –hyperintense lesion in the left centrum semiovale –fresh cerebral infarction? – venous infarction? Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report The next day after admission –Drowsy –Muscle strength of the right limbs declining to grade 3 Before general anesthesia –Stuporous Clinical Center of Neuroscience Changhai Hospital, SMMU

Question 1 Hyperintense lesion of centrum semiovale –Water-shed infarction caused by total steal of the blood flow –Venous infarction caused by venous hypertension and subsequent hypoperfusion? Clinical Center of Neuroscience Changhai Hospital, SMMU

Venous Infarction Kai Y, et al. Neuroradiology, 2009, 51:731 Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report Clinical Center of Neuroscience Changhai Hospital, SMMU

Question 2 Timing of the endovascular therapy –Emergency operation? –Delayed operation (2-3 weeks after cerebral infarction)? –Key points Progressive ischemic stroke Aggravate disturbance of consciousness Over 36hrs after onset of aphasia & weakness Clinical Center of Neuroscience Changhai Hospital, SMMU

Question 3 Strategy –To simultaneously occlude the CCF and oblierate the dissection? –Staged management of the CCF and dissection? –To occlude the ICA? Clinical Center of Neuroscience Changhai Hospital, SMMU

Case Report TAURUS 6/40 WILLIS 4.5/16 10ATM Clinical Center of Neuroscience Changhai Hospital, SMMU

Post-stenting Clinical Center of Neuroscience Changhai Hospital, SMMU

After revival: Drowsy, obey commands, muscle strength grade 4 Blood pressure controlled below 120/80 mmHg Post-operative Clinical Center of Neuroscience Changhai Hospital, SMMU

BP elevated to 140/90mmHg ， left pupil enlarged ， light coma Moderate coma half an hour after that, decerebrate state Died 2 days after hematoma evacuation and decompressive craniectomy 3 Hrs Post-operatively Clinical Center of Neuroscience Changhai Hospital, SMMU

Question 4 Cause of post-operative hemorrhage –Hyperperfusion/reperfusion syndrome –Other? How to avoid and manage it? Grunwald IQGrunwald IQ, et al. Neuroradiology. 2009;51(3):169Neuroradiology. Clinical Center of Neuroscience Changhai Hospital, SMMU