A comatose patient with fixed and dilated pupils, and a very good prognosis. The power of neuroangiography

• A 32-year-old with HTN presented with headache
• GCS 15
• Head CT: Cerebellar bleed
• Transfer to our center planned

While still in ED:

• Patient became lethargic
• Developed left 3RD CN palsy involving the pupil
• Repeat Head CT: stable

Head CTA/CTV

• No clear thrombosis
• Patent deep venous system

 

Upon arrival to our hospital:

• Patient was non-responsive with bilateral fixed and dilated pupils
• Absent oculocephalic reflexes
• Got intubated

Brain MRI

Next step in Management

No aneurysms or arteriovenous shunting

Left ICA Run

Cerebral Venous System

Cavernous sinus and orbital venous thrombosis. Responsible for 3rd CN palsy and proptosis.
Venous thrombosis led to cerebellar bleed.

Venography and Venous Manometry

Venography and Venous Manometry

• IV Heparin
• TS balloon angioplasty
• TS Angiojet thrombectomy
• Raise MAP to improve cerebral perfusion pressure

• Transverse Sinus stenting? NO
• Acute thrombosis state may cause stent thrombosis

MRI-24 hours

• Bilateral border-zone infarcts
• Attributed to decreased cerebral perfusion

Post-op Course (3 days)

• Patient remained comatose. GCS 3
• Fixed and dilated pupils
• Absent oculocephalic reflexes
• Comfort care/PEG-trach were raised by staff
• EVD was contemplated but not placed
• Key problem is reduced cerebral perfusion, not IC

Day-4, Back to Angiosuite

• Right transverse sinus stented
• Pressure gradient eliminated
• SSS pressure dropped to 25 mm Hg

You do not have permission to view this object.

Post-op Course

• Patient woke up
• Extubated in 48 hours
• Discharged in 10 days
• On Dabigatran
• Ophthalmoplegia gradually improved
• Returned to work in 3 months with no deficits