1. A 45 year old man with painful right eye blindness Teaching NeuroImages Neurology Resident and Fellow Section © 2013 American Academy of Neurology

2. 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 3 rd nerve palsy improved and pontomesencephalic edema resolved Alderazi YJ, et al © 2013 American Academy of Neurology

3. Imaging Alderazi YJ, et al © 2013 American Academy of Neurology

4. 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